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STAY WELL UNTIL MONDAY
Doctors and nurses have long held that patients experience worse outcomes if they are admitted to hospital on weekends. Recently, two studies compared weekend and weekday care for patients with upper gastrointestinal bleeding.
The first study found a 22% increase in the risk of death for patients who were admitted on weekends compared with those who were admitted on a weekday. These weekend patients were 64% less likely to undergo endoscopy to define the source of bleeding on the first day of hospitalization.
The second paper evaluated bleeding related to gastric ulcer. Weekend admissions were again associated with an increase in mortality as well as a delay of 2.21 days for endoscopy. There was also an increased rate of surgery to control the bleeding. (Consultant, June 2009, p 360).
MERCK GOES HERBAL
Merck, one of the five largest pharmaceutical companies in the world, has signed a collaborative agreement with Chi-Med, a Chinese producer of botanical medicines. Merck will outsource part of its cancer drug research to Chi-Med, who will draw from its library of around 10,000 herbal compounds to find promising candidates.
Chi-Med currently has two cancer medicines in early clinical development in the USA and China, one for lung cancer and one for inflammatory bowel disease. Chi-Med owns the Sen brand of Chinese medicinal products.
AMERICAN HEART ASSOCIATION GUIDELINES PRODUCE LITTLE AFTER 9 YEARS, TENS OF MILLIONS OF DOLLARS
Now costing 12 million dollars a year, the “Get With the Guidelines” program pushed as a “standard of excellence” by the American Heart Association at 3909 medical centers has been an expensive flop.
When compared with centers that did not subscribe to the program, there was no difference in heart failure mortality and only a 0.19% decrease in survival after heart attacks. After adjusting the data for confounding factors, the decrease in mortality was calculated to be 0.08%, forty three per cent less.
The AHA is predictably ignoring this miniscule benefit and asserts that the program “showed dramatic improvements in care”. However, the cost is enormous and benefit appears nonexistent. (Family Practice News Nov 15, 2009; p 14).
MEDICARE FIX PUT OFF ANOTHER YEAR
As reported last month, the Senate was unwilling to correct the disastrous sustainable growth rate formula that they created for Medicare, so they decided to put it off for another year. Now instead of a 21% percent decrease in physician payments in 2010, physicians will instead receive a 0.5% increase and the decrease in 2012 will be 23%. (Medscape)
Don’t expect Government to ever correct the problems that they have created when it is possible to procrastinate. According to the Tax Foundation’s review of the Congressional Budget Office's (CBO) analysis, the $848 billion health care reform legislation unveiled by Senate Majority Leader Harry Reid is financed primarily through cuts to Medicare provider payments (which would save $330.6 billion, or 34 percent of the bill's 10-year cost) and a 40 percent excise tax on high-value "Cadillac" health plans (which would generate $149.1 billion, or 15 percent of the bill's cost).(Tax Foundation).
HOT PEPPERS AND HEART ATTACKS
Cayenne pepper has been valued for many centuries as a medicine, and modern scientists are slowly rediscovering the value that the ancient world understood. Studies at the University of Cincinnati with mice indicate an 85 percent reduction in cardiac cell death when capsaicin was applied through the skin. This is the most powerful cardio protective effect ever recorded, according to Keith Jones, PhD, a researcher in the UC department of pharmacology and cell biophysics. (Circulation 2009 Sep 15;120(11 Suppl):S1-9).
Although modern clinical evidence is lacking, historically, cayenne has a positive reputation among physicians around the globe. The well known herbalist, Dr. John Christopher stated, "In 35 years of practice, and working with the people and teaching, I have never on house calls lost one heart attack patient and the reason is, whenever I go in--if they are still breathing--I pour down them a cup of cayenne tea (a teaspoon of cayenne in a cup of hot water), and within minutes they are up and around."
Another finding from the University of Cincinnati study is that minor trauma to the skin has a similar heart protecting effect as pepper. Perhaps now that there is a mechanism to explain the clinical benefit seen when heart attack symptoms are treated with acupuncture, this simple and inexpensive treatment may become more available in emergency rooms. Sadly, there are few trained physicians who are likely to be in the right place at the right time to provide this benefit in a timely manner.(Natural News).
BACTERIAL BALANCE AND THE IMMUNE SYSTEM
The various components of the “immune system” work together in a complex fashion to accomplish a variety of tasks. Healing wounds, repairing connective tissue and bones, defending against viral, bacterial and fungal disorders, and detecting and opposing tumors and malignancies are at least a few of the functions provided by the immune systems of the body.
Aside from the evidence supporting moxibustion, acupuncture and some herbal formulas as effective regulators of these systems, dietary modifications can be considered to enhance the correct response of the immune system to challenges. It is important to remember that too strong as well as too weak a response of the immune functions can be counterproductive. This is why powerful drugs are less desirable options to dietary treatments.
Probiotics: Antibiotic residues in food and water, as well as broad spectrum prescribed antibiotics, destroy large numbers of beneficial bacteria in the body. Beneficial bacteria produce vitamins and assist the immune function in an as yet poorly understood way. They also act to prevent more pathologic bacteria from gaining a foothold in the body.
Restoring beneficial bacteria with oral supplements shows some promise for digestive health as well as reducing allergic symptoms and improving response to pathogens. Two areas of the body are generally targeted with supplements: lower bowel bacteria probiotics are usually taken in a form that allows them to survive the passage through the stomach, where conditions are normally such that no bacteria should be present. Probiotics for the mouth, throat and sinuses are a newer option, and are applied with a liquid or lozenge medium into the mouth or nose directly.
Increasing the levels of beneficial bacteria such as S. salivarius in the oropharynx seems to reduce the frequency of infections of the middle ear and throat in children and adults, and may also have benefits for the health of the teeth and gums. Researchers have also documented improvements in dental plague and imbalances in populations of mouth bacteria that lead to bad breath.
Mushroom sugars: One of the more interesting uses of medicinal mushrooms that I discovered while traveling in China was the treatment of malignancies with certain mushrooms. In the 70’s, Chinese researchers had documented improved functions of certain parts of the cellular immune system in cancer patients given extracts of lentinus, ganoderma, and coriolus mushrooms.
Several other mushrooms have since been found to have similar effects, and Japanese researchers have used extracts that are even more potent than the mushrooms themselves. Some research suggests that Hericium species may reduce dementia symptoms, and the use of a Tibetan fungus has been associated with improved cardiovascular and athletic function.
Japanese mushroom extracts tend to be rather expensive in U.S. dollars, but are generally free of side effects. Chinese doctors prefer to give the sugars intravenously as a purified extract, but this option is not available in the United States.
Oral supplements or eating the more palatable mushrooms is the only practical method for using these here. Those who have a concern about malignancies should consult a knowledgeable physician regarding the choices available. Increasing your intake of Pleurotis species or Shitake mushrooms is a suggestion that I have made since the early 80’s: 2 or 3 ounces two or three times a week is a reasonable goal to achieve.
ADJUNCT TO THE MEDITERRANEAN DIET
Taking a siesta in the middle of the day can reduce the risk of death from heart disease, particularly in young healthy men. Data came from a prospective investigation of a general population cohort of 23,681 individuals, who at enrolment had no history of coronary heart disease, stroke or cancer.
Participants were asked how frequently and for how long they napped and their dietary habits and physical activity were also recorded to exclude these as confounding variables. Follow-up was for six years.
It was found that those occasionally napping had a 12% lower rate of coronary mortality, whereas those systematically napping (a 30-minute siesta at least three times a week) had 37% lower coronary mortality.
The inverse association between coronary mortality and napping was particularly evident among men who were working at the time of enrollment (64% reduced risk of coronary death). Authors speculate that the coronary benefits of a daytime siesta may be due to reduced stress levels. (Siesta in healthy adults and coronary mortality in the general population. Arch Intern Med. 2007 Feb 12;167(3):296-301).
PERFECTIONISTS PRONE TO IBS
Perfectionists are more prone to developing irritable bowel syndrome (IBS) after an infection.
A prospective study recruited 620 primary care patients with a positive test for Campylobacter gastroenteritis, who had no previous history of bowel complaints. They completed a questionnaire at the time of infection, which included standardized measures of mood, perceived stress, perfectionism, negative illness beliefs and illness behaviors.
At three and six months after initial infection, participants completed follow-up questionnaires designed to determine whether they met Rome criteria for IBS.
Analysis of the data indicated that those who developed IBS (49 people) had significantly higher levels of perceived stress, anxiety, somatisation (expression of psychological problems as physical symptoms) and negative illness beliefs at the time of infection than those who did not develop IBS.
IBS cases were also significantly more likely to remain active in the face of their acute symptoms until they felt forced to rest (‘all-or-nothing behavior’) and significantly less likely to initially rest in response to their acute illness. (The cognitive behavioral model of irritable bowel syndrome: a prospective investigation of gastroenteritis patients. Gut. 2007 Feb 26; [Epub ahead of print] 2007;0:1–6. doi: 10.1136/gut.2006.108811).
"Is Anyone Thinking?" Department
TWO OF THE WORST IDEAS FOR 2010
BRING BACK THE HOUSECALL
What is old will be new again, with both the Senate and House “reform” bills containing the “Independence at Home Act”. This new bureaucratic money pit will pay for home care as long as providers save Medicare “a minimum of 5% in hospitalization costs and meet certain patient satisfaction and performance standards.”
This program is targeted at “Medicare beneficiaries who have high cost chronic health conditions and also need help with such activities of daily living as bathing and dressing”. In other words, very sick people who are certain to require the highest levels of hospitalization within the Medicare populations.
Good luck meeting those requirements to get paid, doctors!
A managed care company in Maryland is using an ex emergency room doctor to make home visits in a pilot program: By simply comparing the $225 that Medicare pays for a home visit in this trial with a 1200 dollar emergency room visit, it seems that the program makes sense. (“House Calls Eyed as Model to Cut Costs” Family Practice News November 2009 p 1).
But a great deal of the cost is not apparent from such simplistic calculations.
To document all the “care” that is provided, our doctor on wheels will need, of course, “an electronic medical record” and, “miniaturized diagnostic equipment.” What this latter means I am not sure. I had a doctor’s bag that worked very well for me, but all I needed was the usual stethoscope and ophthalmoscope and a few simple tools. Nothing exotic.
I am sure the average congressman expects our doctor to carry a tiny X ray machine and cardiac catheterization equipment, along with the sonic screwdriver from Doctor Who.
Equipment has to be paid for and capitalized, but these numbers don’t appear in the balance sheet in our Family Practice News article.
Software to run the EMR is not free, last time I checked, and there will have to be technicians to maintain the network. Oh, and don’t forget to add the close to $30,000 per physician so he can have access to the codes to make all this wealth spread around.
Also not in the calculations are the cost for the car and the gas and tires for the doctor. Who is going to pay his liability insurance? How about the worker’s compensation cost if he is hit by a drunk driver, or mugged or robbed of his shiny electronic toys?
And, if our doctor is female, what protection will she have against rape or assault in our increasingly crime-ridden society?
Unless patients are living in a small geographic area, travel time is another contributor to expense and inefficiency. Is it really the best use of a skilled doctor’s time to have him where he can’t be seeing patients, out on a road somewhere stuck in traffic behind school buses and pizza delivery trucks?
Won’t there be similar costs for the nursing support that will also have to make house calls to carry out the doctor’s orders? They will also have to have supplies, gloves, equipment to lug around also. Who will buy and maintain their cars? Who will protect them from guard dogs, drug dealers, and thugs? Does Congress envision a fleet of Medicare limos to ferry all these health care workers around?
And, with the present nursing shortage and the expected shortage of primary care doctors, is this really such a good plan? Congress doesn’t care. It’s not their money they are spending. They don’t care if the promised results never materialize. It makes a good sound bite.
I know something about housecalls, as I did these in the early 80’s while establishing my practice. There is simply no way in which these can be an economically viable model for reducing “costs”. As I have editorialized before, however, there is no reason to accept the premise that cutting costs is the most important priority of a medical system.
Yet, “House Calls Eyed as Model to Cut Costs” is the nitwit focus in the Family Practice News article. Doctors themselves have become accomplices in the unthinking worship of the irrelevant priorities of the businessman.
House calls are actually a very good way to find out a lot of information to help manage a situation, as well as establish and maintain a relationship, but this takes time and effort. Having “miniaturized diagnostic equipment” won’t make it easier.
And, without effective visiting nurse backup, and close monitoring (both rather expensive), they won’t make any difference to outcomes. You don’t get something for nothing, unless you believe the promises of politicians.
As an excellent example of this sort of fantasy thinking, our elected elite will manage to “pay” for all of the reform by finding “savings” in Medicare. Somehow, they have managed convince themselves that they can pay for more spending in Medicare with savings from the same program. Astonishing.
And, spending more will decrease the deficit also!
Anyone who believes that you can spend more and save more simultaneously lives in another economic dimension from the rest of us, but since so few seem to be aware of this astonishingly bold lie, Congress and the Executive branch are apparently succeeding in slipping this past the awareness of the American people.
JUST DO IT FOR FREE
Doctors in five states are experimenting with a “solution” to the “problem” of patients “losing their health insurance or postponing care they can’t afford”. (Medical Economics Dec 18, 2009 p 18)
The radical solution? Expect professionals to see patients for no charge.
An organization known as Project Access has developed to utilize charitable donations and tax dollars to create a “community led collaboration of physicians, hospitals and pharmacies to provide healthcare to the low income uninsured”.
Sounds noble, doesn’t it? But what if we changed the language a bit to expose the nonsensical nature of this “solution”: “Project Transport is a community led collaboration of mechanics, car dealers, and gas stations to provide cars to those who can’t afford them.”
There is nothing wrong with charity. Citizens of the U.S. are among the most generous people in the world when it comes to helping those in need. But here, the need is created by a wealth sucking bureaucracy that has impoverished not only the patient, but the provider as well.
The solution is not to fund a new bureaucracy with donations and tax dollars, but to eliminate the corrupting influence of the medical industrial complex.
The myth that doctors cannot work without an expensive third party mechanism to funnel funds to them lies behind the well meaning, but ultimately foolish solution of “Project Access”: Patients lose their health insurance when they lose their jobs because of the corrupting requirement that employers control funding for medical care for their employees, when they are unsuited for the task by both training and by temperament.
Patients are impoverished by health care because their “insurance” does not cover all of their expenses, insurance companies are empowered by law to include weasel clauses that create yearly deductibles, exempt “pre-existing conditions”, and inflate prices beyond all reason by an insider system that provides steep discounts to large organizations, but balances uncontrolled costs on the heads of the individual and the small businessman.
Permitted monopoly power and exempted from antitrust rules by the same lawmakers, they can set fees and payments at any level they please, or deny payment at a whim with no fear of consequences.
The bureaucrats of “Project Access” are paid, but the doctors are not. They can provide care for free, but there is still an expense for the doctor’s time, supplies, and overhead. Liability doesn’t go away, thanks to the untiring efforts of the Association of Trial Lawyers of America (now known as the American Association for Justice)
In Tennessee, a law was passed to protect physicians from “frivolous” lawsuits for physicians who donate 100 per cent of a patient’s care.
However, if the care is “negligent”, the doctor can still be sued and found liable for judgment. As anyone can sue anyone in America for anything, the costs for defending a lawsuit and the risk of being found “negligent” by a jury is still borne solely by the physician.
In the past, charity care was a standard that many doctors could meet. The idea that by doing well one could do good, was embedded in the idea that physicians were not low level technicians who could just barely meet their expenses. But, in the modern world doctors face a reality where they are expected to train for 10 to 15 years (at enormous and also inflated cost that induces most to take on enormous debt), and then practice in an environment where any deviation from perfection is grounds for a career crushing judgment.
Add in all the unfunded mandates for the medical system to address every societal problem, restrictions on income with no control on overhead, and the constant interference in daily life that lawmakers, regulators, social engineers, and auditors can dream up, and you have created a system that guarantees failure.