Hospitalized Seniors Say No One Coordinates Their Care

Anthem Healthcare had a survey conducted of over 1,000 senior citizens older than 65 years of age in the hospital between September 26 and October 13, 2016. This Harris Poll found that 85% of the participants had a real medical issue. The poll also indicated:

Sixty-four (64%) percent said they had at least three different health care providers (at one time these were called doctors.)

  • Sixty-nine (69%) percent rely on a family member or themselves to organize and coordinate their care.
  • Sixty-four percent (64%) of those recently hospitalized said no one helped coordinate their care after their hospital discharge for months at a time.
  • Less than half of those surveyed (<50%) said that they were asked about medications or treatments provided by other physicians that might impact their current care. With no one checking drugs and drug interactions this raises major safety issues.

The findings are not surprising to me and reinforce why I limited my practice size and leave sufficient time to learn about who else is caring for my patients and what, and why, they are recommending their specific care plan. It requires reviewing medication lists painstakingly including accessing pharmaceutical data bases and asking patients and their caregivers to bring all their medications and supplements to the office in their original pill bottles. For instance, you can’t tell how much potentially dangerous fat soluble vitamins your patients are ingesting without reading the labels. You need to run the drug-drug interaction software to insure that medicine combinations are not making your patient ill

It’s important to know who else is providing care to this patient and why. As their primary care physician, you need to ask patients to request old medical records and request a consult summary from their other doctors.   You then need to invest the time necessary to review these documents.  It’s a two-way street; providing your patients’ other physicians with your office notes as well as lab and test results. Sometimes a phone call to another doctor is necessary to clarify treatment recommendations and to then assist and educate your patient concerning the reasoning and goals of the treatments.

Often, family conferences in person or by phone are needed to inform caring relatives about what support and assistance the patient requires and how they can be of help. It takes time listening to your patients’ concerns, advocating on their behalf and preventing well-meaning treatment from others from causing harm because they are unaware of the patient’s medication or problem list.

In today’s world, concierge and direct pay primary care practices are providing these services while polls sponsored by mega-health entities confirm those organizations are falling far short in doing so!

Non Invasive CT Angiography Preferable To Stress Testing

Coronary CT Angiography appears to be a better tool than stress testing alone for identifying patients with chest pain requiring invasive angiography. The SCOT-HEART investigators showed that patients showing disease on CT Angiography were less likely to show normal coronary arteries when they had the subsequent cardiac catheterization or angiogram. The SCOT-HEART study included 4146 patients who were randomized to receive standard care with or without coronary CT Angiography. David E Newby, MD, of the University of Edinburgh in the UK and associates concluded in the April on line edition of the Journal of the American College of Cardiology “in patients with suspected angina due to coronary heart disease, coronary CT angiography leads to more appropriate use of invasive angiography and alterations in preventative therapies that were associated with a halving of fatal and non-fatal myocardial infarction(s).” Reviewers of the study in editorial comments said that CT angiography had an edge over stress testing because of,” The ability to identify, quantify and characterize atherosclerosis.” CT angiography allows measurement non- invasively of fractional flow reserve providing a clear advantage to traditional stress testing. The major draw backs to CT angiography include cost of about $460 more than stress testing and exposure to ionizing radiation. A traditional CT scan exposes you to about 10 years’ worth of Chest X Ray level radiation.

For the practicing community physician this data will result in our patients with chest pain being sent for Coronary CT Angiography in the Emergency Department when presenting with chest pain, risk factors for heart disease and no clear cut diagnostic EKG changes instead of waiting for a cardiologist and technical team to be available to perform a stress test.

Legalization of Medical Marijuana and Traffic Fatalities

The State of Florida has legalized marijuana for medical purposes. Marijuana has now been legalized for medical use in 28 states.

We know that marijuana and or alcohol impairs ones driving ability. Surprisingly, the traffic fatality rate dropped by an average of 11% in states that have legalized medical marijuana since 1996. At the moment researchers have no explanation for this finding. They believe marijuana users stay home off the road and use their medication while individuals drinking alcohol are more likely to drive to or from an establishment serving alcohol.

The state of Colorado has legalized marijuana for general recreational use. They do not yet have data on traffic fatalities and marijuana usage.

Red Meat May Not Increase The Risk For Vascular Disease But Is It Healthy?

A study published in the online version of Consultant 360 magazine looked at the relationship between eating red meat and cardiovascular risk factors. The study was performed at the Department of Nutrition Science at Purdue University. Researchers reviewed 24 studies on the topic listed on PubMed, Cocrane Library and Scopus databases. These studies examined individuals 19 years old or older who consumed at least 35 grams of red meat per day and whom listed at least 1 cardiovascular risk factor. They then examined the study participants blood total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides plus systolic and diastolic blood pressures.

They found that red meat at these quantities did not increase lipids, lipoproteins or blood pressure. This led them to conclude that the risk for cardiovascular disease did not increase in individuals consuming more than the recommended daily amount of red meat.

While this study gives hope to meat lovers, cardiovascular disease is not the only cause of illness or death. High consumption of red meat has been implicated in a greater risk of developing colon cancer, breast cancer, diabetes and an overall increased risk of death from all other causes. Some individuals seem to believe that you can counteract this negative effect of red meat by eating large quantities of fresh fruits and vegetables. Unfortunately a Swedish study published this year in the American Journal of Clinical Nutrition disproved this theory. For men, the more red meat they ate the more likely they were to develop diabetes. For both women and men, those who ate the most red meat had a 21% greater risk of all – cause mortality than those who ate the least. This higher risk did not change when the authors took into account fruit and vegetable intake. Interestingly it was processed meat that caused the rise in health risk with unprocessed meats only being associated with a slightly increased death risk even at high consumption levels.

I believe the take home advice is that consumption of unprocessed red meat in moderation with plenty of fresh fruits and vegetables doesn’t impair your risk of dying. Processed meats are to be avoided if you wish to avoid multiple illnesses and disease. Give up the bologna and salami and other processed meat products except on limited occasions.

New Common Cold, Alzheimer’s and Influenza Vaccines on the Horizon

On a regular basis I see patients miserable with symptoms from a viral upper respiratory tract infection or common cold. They run fevers, are chilled, ache all over, have painful burning throats, runny noses, sinus congestion and just feel miserable. Our therapeutic options include only rest, warm fluids, throat lozenges, cough medicines and aspirin type medications. Antibiotics do not work against viral illnesses.

Researchers at Emory University have developed a vaccine for the common cold. It contains 50- 100 of inactivated Rhinoviruses. Rhinoviruses cause 60-80% of our common colds. Rhinovirus is the most common pathogen exacerbating infections in patients with asthma and emphysema.

The initial work on this vaccine began 60 years ago but the sheer number of different Rhinoviruses, coupled with the limited technology of that time period, prevented progress. With today’s technology researchers have been able to administer 50 or more inactivated Rhinovirus variants to mice and monkeys producing neutralizing antibodies and preventing these infections. Human trials are scheduled to begin shortly with the expectation that a vaccine may be available in two years. The initial recipients will be high risk patients with COPD and asthma but all others will be able to receive the vaccine as well. They believe the immunity will last for two years and then a booster will be required.

There is a new vaccine for influenza prevention in adults 65 years or older being produced which will cover all four of the common viral influenza variants. Currently Fluzone is the senior high dose vaccine recommended to prevent the three most common A viruses. There is a B1 virus seen in the spring that is not in that product. Younger adults receive a Quadrivalent flu vaccine that includes the B1 virus. Within the last four weeks Flublok has been approved by the FDA and released as a high dose vaccine which contains the three A viruses in inactivated form plus the B virus. It will be the vaccine of choice in the 2017 fall flu season. This new vaccine was produced with new DNA technology which allows it to be egg free and received by individuals allergic to egg products. Most other vaccines are grown in egg cultures and individuals with egg sensitivity cannot receive them.

Researchers in the United States and Australia have developed a vaccine to prevent and treat early and late Alzheimer’s disease. It targets the proteins found in the brains of Alzheimer’s disease in the early and late stages. The vaccine has met with success in early animal studies and is beginning formal Phase I studies this winter. They believe this vaccine can reverse some of the symptoms seen with the disease. While the early results are encouraging, this product is a minimum of seven to eight years from being available as a commercial product.

For Arthritis of the Knee, Glucosamine and Chondroitin Sulfate is the Best Medicine to Control Long Term Symptoms of Joint Change

A paper presented at the recent American College of Rheumatology annual meeting reviewed all the research results on use of medications to control joint changes and pain in arthritic knees caused by osteoarthritis. Lucio C, Rovati, MD, of the Clinical Research Department of Rottpharm Biotech, Monza, Italy and the University of Milano Vicocca, Milano, Italy and colleagues presented the first systematic review and meta-analysis to investigate the effects of available medication used for at least a year to treat knee osteoarthritis. Their findings were published in the online journal MedPage Today. They reviewed 5992 articles discussing treatment with acetaminophen, calcitonin, celecoxib (Celebrex), chondroitin sulfate, hyaluronic acid, indomethacin, naproxen, vitamin D and zoledronic acid plus several others. The only medication that had a significant long term beneficial effect on pain and physical function was glucosamine and chondroitin sulfate. This does not mean that Tylenol, Aleve, Advil, Celebrex or other nonsteroidal anti-inflammatory drugs did not provide some immediate short term pain relief. It means that over a year they didn’t maintain the joint integrity and consistently maintain or improve function.

Need To Expand the Recommendations for Screening for Lung Cancer in Former Smokers

In 1976 when I began my internship in internal medicine almost all cigarette smokers 35 years of age or older received an annual chest x ray to screen for lung cancer. In the 1990’s as managed care and insurers’ stopped paying for these screenings, we were told by the experts that the cost of saving one life by looking at every smoker was not cost effective. Insurance companies stopped paying for these films at the same time that medical advisory boards insisted on clinicians sending their chest x-rays out to be read by radiologists, adding extra costs to each film.

The practice of routine screening virtually disappeared. With it came a large increase in the number of smoking related deaths from lung cancer. It took the “experts” almost two decades to realize the errors of their decision.

In 2014 the US Preventive Services Task Force endorsed performing low dose computed tomography (CT Scans) in patients who were a high risk for lung cancer. This group was defined as individuals aged 55 to 80 years who had smoked at least 30 pack years (computed as number of packages of cigarettes smoked per day times the years the individual smoked) in individuals who continued to smoke or had quit within the last 15 years. The data to back up this recommendation came from Ping Yang, MD, PhD and colleagues at the Mayo Clinic. Their research and the new recommendations have helped reduce lung cancer deaths by 20%.

Since these recommendations were instituted, Dr. Yang and colleagues have continued to evaluate the guidelines. They found that individuals who quit smoking 15 -30 years ago are being diagnosed with lung cancer at a rate of 12-17 % of the newly diagnosed cases. They consequently are now recommending that we screen all adults 55- 80 with a 30 pack year history even if they quit more than 15 years ago.

The US Preventive Services Task Force which produces the recommendations that insurers consider has not yet endorsed this suggestion. In our practice we will be recommending low dose CT lung scanning annually on all our smokers who meet the Mayo Clinic criteria. If you, as my patient, fall into that group and have not been getting annual low dose CT Scanning of the lung for lung cancer detection please let us know so that we may set up a surveillance program. We understand the increased cost and ionizing radiation exposure that CT Scans involve but Dr Wang’s research suggests that the benefits outweigh the costs and risks.