Disease Focused Disorders
A study just published in NEJM indicates some of the consequences of specific heart disease and diabetes treatments.
“The study, by researchers from the US Centers for Disease Control and Prevention (CDC), singles out 4 drugs and drug classes — warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67% of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33%, lead author Daniel Budnitz, MD, MPH, director of the CDC's Medication Safety Program, and coauthors write.”
Via Medscape Article at http://www.nejm.org/doi/full/10.1056/NEJMsa1103053#figure=t1
Hospital interventions will not work well to address these situations.
Physician interventions have not worked well.
Patient interventions are not likely to work mainly because we often understand so little about patients and even fail to include patient factors in most such studies. Health literacy rates are lower in the elderly, caregivers are important factors, living conditions vary and change because of hospitalizations, etc. Also we are finding out that readmissions to hospitals can greatly be reduced when someone actually visits the home of the patient - what a novel and innovative idea only centuries old.
If the focus continues to be stamping out disease or evidence of disease, people in the United States and worldwide (Myth for the Cure) will have even more problems with warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Chemotherapy reactions, infections resulting from treatments, and reactions resulting from antibiotics used in treatment are also problem areas.
Note that “High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations.” Those inside of hospitals making up the definitions of high risk can be off target.
This is only the tip of the iceberg regarding too much done for too few with too little result. Consequences such as these insure even more done for much greater cost and ever greater potential for adverse outcomes. This also results in less and less remaining for important basic health care services that keep getting bypassed in funding priorities – so not surprisingly one factor that could improve the outcomes is compromised.
The outlook for 2012 is a worsening of primary care, particularly for the elderly who need 2 to 3 more times primary care due to age. Matters will be even worse for those who need the most care. Good luck finding primary care for Medicare patients that have not established care somewhere. At some point the lawyer advertisements will note “Did your hospital send you home too soon? Did your hospital physician send you home on Coumadin, insulin, Plavix, or metformin? Call 555-SUEBYME” and add to the Four Diseases problem of the US - especially greed. Obviously the lawsuit interventions have also not done much to improve care despite trial lawyer claims.
What will work?
Doctors must be more aware of patients, patient situations, and patient limitations before training, during training, and after training. If they are not aware before training, they are not likely to improve after training. They will do too much for patients that will consequently have more adverse events.
Physicians who are more likely to know their patients are may also be less aggressive in treatment – a policy that is good for some patients and not as good for some, but is less likely to result in emergency hospitalizations and adverse events. Being ridiculed or rated lower in quality is a consequence of being aware of your patients. But the best care for patients is about the patient and situation rather than being guideline perfect.
Treating patients all the same with the same guidelines appears to be contraindicated for best results.
This is why guidelines regarding aspirin, beta blockers, anticoagulants, and measures of diabetes outcomes must be processed by the primary care nurses, physicians, and practitioners that know the patients and their situations rather than prosecuted as in Pay for Performance, system requirements, other insurance company measures, or other guidelines.
The One Million Hearts Campaign going on now champions more done despite not enough understanding, awareness, and primary care workforce. How many more adverse events will arise?
Note that patients are often placed on aspirin, beta blockers, anticoagulants, hypertensive medications, heart medications, and diabetes medications during a hospitalization BUT THOSE WHO BEGAN THE MEDICATIONS ARE OFTEN NO LONGER PART OF THE CARE.
Insurance companies force the primary care doctors and nurses to pick up the responsibility even though the patient was sent out before stabilization, before the side effects were known, and before adequate follow up was assured – a nice result of the US hospital and hospitalist design and the US design that defeats enough primary care workforce and overloads primary care nurses. By shifting the workload and responsibility, this was another indication of irresponsibility in health care design and implementation.
“With an estimated 21,010 hospitalizations for warfarin-related hemorrhages, the cost for this one type of adverse drug event is probably hundreds of millions of dollars annually.24” Actually a better estimate would be over 1 billion to as much as 5 billion. These are not cheap hospitalizations when brains, lungs, and other organs are involved. Low cost hemorrhages do not get hospitalized. These costs do not include rehab of brains, lungs, joints, etc. or costs to caregivers and the nation in productivity.
Consider the cost of 250,000 annual ER visits ranging from $500 – 2000 per visit then there are urgent care, office visits, hospitalizations, placements in long term care, and deaths.
Thanks to all 12,000 who have visited Basic Health Access in 2011.
Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
The consistent theme is too much done for too few with too little result. Consequences insure even more done for much greater cost with ever greater potential for adverse outcomes. Basic health care services are also compromised by this design that sends ever more dollars to more different diseases resulting in few remaining to collaborate with patients, families, caregivers, specialists, and health care teams to optimize care and minimize consequences.