It’s okay and important to ask your doctor “DID YOU WASH YOUR HANDS?”

Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer*, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me.

“Most patients wouldn’t dare to ask their doctor to wash his or her hands..” It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse…” (A)

Some hospitals post signs in each examination room encouraging patients to be vigilant about doctor hand-washing; one even gives patients a card stating “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.” (B)

 

Some background on Hospital Acquired Infections:

Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene. (C)

“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (D)

“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (E)

“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. “ (F) (G)

 

Protect yourself! Start by asking your doctor, nurse, phlebotomist, physical therapist and others –

DID YOU WASH YOUR HANDS? 

 

* “It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips.” (H) “A study… suggests that dangerous bacteria may be spread by health care workers’ clothing.” (I)

 

 

(A)    Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’ by Laura Landro  http://online.wsj.com/news/articles/SB10001424052702303918804579107202360565642?KEYWORDS=hospital&mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702303918804579107202360565642.html%3FKEYWORDS%3Dhospital

(B)   It’s okay to ask your doctor: “Did you wash your hands?”, by Paul Taylor, http://healthydebate.ca/personal-health-navigator/okay-ask-doctor-wash-hands

(C)   Hand Washing Stops Infections, So Why Do Health Care Workers Skip It? ,  by Sanjay Saint, http://labblog.uofmhealth.org/industry-dx/hand-washing-stops-infections-so-why-do-health-care-workers-skip-it

(D)   What Zero Looks Like: Eliminating Hospital-Acquired Infections, http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx

(E)    Hospital-acquired infections rack up $9.8B a year, by Julie Bird, http://www.fiercehealthcare.com/healthcare/hospital-acquired-infections-rack-up-9-8b-a-year

(F)    Guidelines for prevention of hospital acquired infections, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/

(G)  Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene, http://www.jstor.org/stable/10.1086/677145

(H)   How dirty is your Qwerty? by Dan Childs   http://abcnews.go.com/Health/Germs/story?id=4774746&page=1

(I)     Do white coats, scrubs, stethoscopes, cell phones and computer keyboards collect dangerous hospital germs?, by Joe Graedon, https://www.peoplespharmacy.com/2016/11/03/are-doctors-and-nurses-transporting-deadly-hospital-germs/

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UBER HEALTH Inc., WALMART HOSPITALS NFP, AMAZONrx (Ireland), MicrosoftCare LLC.

I just got an urgent cold call from a Financial Advisor recommending I buy warrants  in UBER since it is about to announce the opening of  a system of  “gig” urgi-care, UBER HEALTH.

You will be able to get a doctor to make a house call within ten minutes using a new UBER HEALTH APP. . If the doctor prescribes an MRI an imaging van will be sent to your house within one hour. Read by a radiologist somewhere in the ethernet.

There will be surge pricing and competition from LYFTparamedic.

Further research disclosed:

IBM WATSON DX will enable you to self-diagnose your health problems and treatment plans through secret proprietary algorithms, while the doctor is on the way.

APPLE MEDICAL SCHOOL will have virtual clinical rotations in medicine, pediatrics, surgery and obs/gyn, where students will deliver virtual babies.

WALMART HOSPITALS will become the anchor hospitals in many communities, right across from Walmart stores.

BLACKROCKdoc will employ 75% of physicians, with practice purchases funded by creating clinical derivatives.

AMAZONrx will dominate the mail order prescription medicine market.

MICROSOFTcare will capture 50% of the health insurance market driving Aetna, United and the Blue Cross plans out of business.

YAHOOlitigator will be do malpractice trolling akin to reverse mortgages.

To quote President Trump “nobody knew that healthcare could be so complicated”…

So I am going to sell all these stocks short.

 

 

 

 

 

 

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With recurring infection should Congressman Scalise have been transferred to another hospital rather than to the ICU where he is hospitalized?

About twenty years ago as President of LibertyHealth each of our hospitals (a medical school affiliated teaching hospital and two community hospitals) had an ICU. I was always concerned that sometimes patient acuity in one of the community hospital ICUs might have exceeded its capability and pushed for clear clinical threshholds for patient transfer to the teaching hospital ICU.
Which brings me to Congressman Scalise…
“A lone gunman who was said to be distraught over President Trump’s election opened fire on members of the Republican congressional baseball team at a practice field in this Washington suburb on Wednesday, using a rifle to shower the field with bullets that struck four people, including Steve Scalise, the majority whip of the House of Representatives.”
“His injuries are extensive, and he was in critical condition Wednesday night, MedStar Washington Hospital Center said in a statement. As the bullet traveled across his body, it broke bones, tore up internal organs and caused major internal bleeding.
Doctors operated immediately, but additional surgery is required, the hospital said.” (A)

Mr. Scalise underwent several surgeries last month, and his condition improved from critical to fair. However, hospital officials on Wednesday said he was moved back to the ICU. Mr. Scalise had another surgery Thursday to manage infection and is now in serious condition, according to the report.
Soon after his rehospitalization, attention shifted toward Washington Hospital Center’s publicly available grades for patient safety and care quality. The Leapfrog Group gave Washington Hospital Center a D in hospital safety ratings for 2016, and CMS’ Hospital Compare website shows the hospital earned 2 out of 5 stars in the most recent update.
“[I]nfections [at the hospital] are a pattern and a serious one,” Leapfrog Group CEO Leah Binder told USA Today. “They are significantly below the national average in four out of five areas that we have data, which suggests an inability to prevent infections.” (B)

a little old (2014)
“Staff at the region’s largest private hospital — MedStar Washington Hospital Center — have given it consistently low marks in key areas of patient safety over the past four years, according to results released Friday.
Although doctors’, nurses’ and administrators’ perception of patient safety has improved during that time — in some cases significantly — the hospital scores below the national average in seven out of 12 patient safety measures in key areas, including the overall perception of safety at the hospital and the ability of staff to report mistakes without fear of punishment.”

June, 2017
“Like many other hospitals across the country, MedStar Washington Hospital Center has been experiencing the financial impact of numerous changes in health care,” the statement from MedStar said. That has included the nationwide nursing shortage that forced the health system to use agency nurses to fill critical positions, as well as “inflationary pressures” that have driven up costs of pharmaceuticals and medical supplies.
MedStar officials also pointed to investments in the last year that have required additional staff, such as the creation of a Sepsis Response Team and the Behavioral Emergency Response Team, that have impacted the budget. The health system saw positive effects from those investments, such as reductions in hospital-acquired infections, and it intends to leave those teams intact, officials said. (C)

 

So I would be digging deeper…..but understand this can be quite frustrating
The U.S. News analysis of hospitals includes data from nearly 5,000 centers across multiple clinical specialties, procedures and conditions. Scores are based on a variety of patient outcome and care-related factors, such as patient safety and nurse staffing. Hospitals are ranked nationally in specialties and regionally in states and major metro areas. U.S. News assigns a rating to hospitals in a handful of common procedures and conditions, including hip replacement and COPD. This hospital achieved the highest rating possible in 5 procedures or conditions.
To see the U.S. News rankings of MWHC highlight and click on http://health.usnews.com/best-hospitals/area/dc/medstar-washington-hospital-center-6330120

The information on Hospital Compare:
Helps you make decisions about where you get your health care
Encourages hospitals to improve the quality of care they provide
In an emergency, you should go to the nearest hospital. When you can plan ahead, discuss the information you find here with your health care provider to decide which hospital will best meet your health care needs.
To see Hospital Compare’s ratings of MWHC highlight and click on https://www.medicare.gov/hospitalcompare/profile.html#profTab=0&ID=090011&loc=WASHINGTON%2C%20DC&lat=38.8951118&lng=-77.0363658&name=MEDSTAR%20WASHINGTON%20HOSPITAL%20CENTER&Distn=3.3

Completed by more than 1,800 hospitals annually, the flagship Leapfrog Hospital Survey collects safety, quality, and resource use information you can’t find anywhere else. We report on the issues that matter to patients and purchasers—from maternity care and surgical outcomes, to handwashing policies and nursing standards.
To see Leapfrog’s report on MWHC highlight and click on
http://www.thehoya.com/medstar-safety-ranks-low/
http://www.hospitalsafetygrade.org/h/washington-hospital-center
http://www.leapfroggroup.org/hospitals/search/list/location/Washington%2C%20DC%2C%20United%20States/10

An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
To see JCAHO’s most recent accreditation report for MWMC highlight and click on
file:///C:/Users/Jonathan/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/6308qr.pdf

whew! That’s hard work

Maybe we need to designate levels of ICUs just as we do for trauma centers and perinatal centers.
Here’s one example:

LEVELS OF INTENSIVE CARE UNITS (D)
LEVEL 1: should be capable of providing immediate resuscitation and short-term cardiorespiratory support for critically ill patients; will also have a major role in monitoring and prevention of complications in “at risk” medical and surgical patients; must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours
LEVEL II: should be capable of providing a high standard of general intensive care, including complex multi-system life support, which supports the hospital’s delineated responsibilities; minimum of 6 beds
LEVEL III: a tertiary referral unit for intensive care patients should be capable of providing comprehensive critical care including complex multi-system life support for an indefinite period; should have a demonstrated commitment to academic education and research; All patients admitted to the unit must be referred for management to the attending intensive care specialist; all consultants are FCICMs; may have over 50 beds, should include pods of 8-15 beds
PICU: as for a Level III unit, but dedicated to the care of pateints under the age of 16 years

(A) Steve Scalise Among 4 Shot at Baseball Field; Suspect Is Dead, by Michael D. Shear et al, https://www.nytimes.com/2017/06/14/us/steve-scalise-congress-shot-alexandria-virginia.html
(B) Medstar hospital’s poor safety ratings get limelight as it treats Rep. Steve Scalise, by Mackenzie Bean, http://www.beckershospitalreview.com/quality/medstar-hospital-s-poor-safety-ratings-get-limelight-as-it-treats-rep-steve-scalise.html
(C) MedStar Washington Hospital Center gets low marks from staff on key safety issues, by Lena H. Sun, https://www.washingtonpost.com/local/medstar-washington-hospital-center-gets-low-marks-from-staff-on-key-safety-issues/2014/07/18/94f3643e-0e95-11e4-b8e5-d0de80767fc2_story.html?utm_term=.d762fccecd67
(D) ICU Design and Staffing, https://lifeinthefastlane.com/ccc/icu-design-and-staffing/

 

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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For 17 years I was President and CEO of a safety net hospital. TrumpCare will “disinsure” twenty million+ people and devastate the hospitals we all depend on.

A little background….

I was appointed President and CEO of Jersey City Medical Center (JCMC) in 1989, one year after JCMC had been converted to not-for-profit governance after a long and colorful history as a public hospital (including bankruptcy protection from 1982 to 1985). JCMC was and still is Hudson County’s (500,000+ residents) regional referral center “safety-net” hospital.

“As defined by the Institute of Medicine, the health care safety net comprises hospitals and other providers that organize and deliver a significant level of health care and other health-related services to patients with no insurance or with Medicaid. Often referred to as providers of last resort, safety-net hospitals (SNHs) have historically assumed a major role in the provision of comprehensive services to medically and socially vulnerable populations.” (A)

When I started New Jersey Hospitals were reimbursed through an all-payor state rate-setting system for Medicare, Medicaid, and commercial insurance, which assured hospital financial stability if managed effectively.
This was coupled with a robust Certificate of Need (CN) process which rationed approval of certain tertiary care services to assure access to them throughout the state, rather than based on a hospital’s fiscal situation, since approved CNs garnered additional reimbursement in reimbursement rates.

Already the sole designated paramedic provider for the County, together rate-setting and CN allowed JCMC: to apply for and be designated as a Regional Perinatal Center (1992), Level Two Trauma Center ((1994), and Medical Coordination Center for Emergency Preparedness (2003); and build a total replacement hospital on a new site (CN approved in 1986, hospital opened in 2004) where an Open Heart Surgery CN (approved in 1999) was started. JCMC became a state approved Children’s Hospital in 2000. Along the way JCMC became LibertyHealth adding two community hospitals, Greenville and Meadowlands (which in 1996 opened a CN designated inpatient rehabilitation unit). In 1997 JCMC became a major teaching affiliate of Mount Sinai School of Medicine (now Icahn School of Medicine at Mount Sinai).

All as a safety-net hospital.

Why am I writing all this?

“Hospitals that primarily serve low-income patients could collectively lose $40 billion in funding over the next decade if the Affordable Care Act is repealed and not replaced by something comparable, according to a new analysis by America’s Essential Hospitals.
That amount represents lost coverage and cuts to Medicaid and Medicare disproportionate share hospital (DSH) funding from 2018 through 2026. The ACA called for those cuts because hospitals would have theoretically needed that funding less as more people gained coverage on the marketplaces and through Medicaid expansion.” (B)

“People with health insurance tend to think of safety-net hospitals the way airline travelers think of the bus: as a cheaper service they would use only if they had to. But without these essential hospitals — which specialize in the care of our country’s most medically and financially vulnerable, particularly the uninsured — our entire health care system would be in danger.” …
For uninsured patients, lifesaving surgeries and treatments, along with a limited recovery period, are often covered through Emergency Medicaid funds. But patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in. “(C)

“Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare bones plans that will be insufficient to properly address their needs. As the nation’s medical schools and teaching hospitals see every day, people without sufficient coverage often delay getting the care they need. This can turn a manageable condition into a life-threatening and expensive emergency.” (D)

“In short, Democrats are focused on trying to maximize the number of people who have decent health insurance, and are willing to accept whatever tax increases and arrangements with health insurers and other private interests are needed to make that happen. They seek the broadest possible availability of health care, whatever the cost and political trade-offs it takes to achieve it.
Republicans are focused on trying to minimize taxes, especially on investment income, and keeping federal subsidies for health care to a minimum. They are willing to accept the wrenching consequences that attaining those goals might have for Americans’ insurance coverage, betting that lower taxes and smaller government will fuel a more vibrant economy.” (E)

 

(A) https://www.hcup-us.ahrq.gov/reports/statbriefs/sb213-Safety-Net-Hospitals-2014.pdf
(B) http://www.modernhealthcare.com/article/20170209/NEWS/170209902
(C) https://www.nytimes.com/2017/05/26/opinion/sunday/safety-net-hospitals-health-care.html
(D) http://www.beckershospitalreview.com/hospital-management-administration/9-organizations-react-to-senate-gop-healthcare-bill.html
(E) https://www.nytimes.com/2017/06/23/upshot/the-health-debate-shows-what-both-parties-care-about-most.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

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On July 4th as we respect and admire hospital staff members who are working 24/7, it is interesting to look at hospital care during the Revolutionary War

From 1967 to 1970, during the Vietnam War, I served first as a 2nd Lieutenant and Chief Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

Here’s what hospital care looked like during the Revolutionary War period.

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:
“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospitals staff numbers varied on how many wounded it served and the severity of the wounds….
Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was amputate it. Where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There was no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistant would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound, and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….
Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well. (C)

Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place.
Four hospital districts were created: Easter, Northern, Southern and Middle. The wage scale was as follows: Director General’s pay $6.00 a day and 9 rations; District Deputy Director $5.00 a day and 6 rations; Senior Surgeon $4.00 a day and 6 rations; Junior Surgeon $2.00 and 4 rations; Surgeon mate $1.00 and 2 rations.
After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….
It seems there was carelessness in making necessary health reports, consequently Washington ordered on January 2, 1778: “Every Monday morning regimental surgeons are to make returns to the Surgeon Gen’l. or in his absence to one of the senior surgeions, present in camp or otherwise under the immediate care of the regimental surgeons specifying the mens names Comps. Regts. and diseases.” [Weedon’s Valley Forge Orderly Book, p. 175]
January 13, 1778. “The Flying Hospitals are to be 15 feet wide and 25 feet long in the clear and the story at least 9 feet high to be covered with boards or shingles only without any dirt, windows made on each side and a chimney at one end. Two such hospitals are to be made for each brigade at or near the center and if the ground permits of it not more than 100 yards distance from the brigade.” [Weedon’s Valley Forge Orderly Book, p. 191] The Commander-in-Chief always solicitous about the comfort of his soldiers issued the following order January 15, 1778: “The Qr. Mr. Genl. is positively ordered to provide straw for the use of the troops and the surgeons to see that the sick when they are removed to huts assigned for the hospital are plentifully supplied with this article.” [Weedon’s Valley Forge Orderly Book, pp. 192-199-204-216] “ (D)

(A) https://brianaltonenmph.com/6-history-of-medicine-and-pharmacy/hudson-valley-medical-history/revolutionary-war-doctor/
(B) https://prezi.com/uwl_a877t2ia/hospitals-and-medicine-during-the-revolutionary-war/
(C) http://www.dosespot.com/medicine-in-the-revolutionary-war
(D) http://www.ushistory.org/valleyforge/served/surgeons.html

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“To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays…”,

“The drug industry was more than willing to meet the need of increased opioid administration and more than willing to advance its usage…..
Adding to this pressure to overprescribe powerful analgesics was the decision by Medicare to adjust payments to hospitals according to their Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This naïve thought put medical treatment on par with any other commodity. But, medicine is different—often patients have an erroneous view of what is in their best interest. Thus, they may be dissatisfied with appropriate medical decisions. In response, many hospitals have fostered a hotel-like approach to please patients.
This practice has led to patients being discharged with a plethora of powerful analgesics to assure hospitals receive excellent scores.
These series of missteps by the medical establishment, the government and public desire has led, in our nation, to drug overdoses (primarily opioids) as the leading cause of accidental deaths.” (A)

“In a recent letter to the Health and Human Services inspector general, Johnson noted that opioid problems appeared much worse from 2013 to 2015 in states that expanded Medicaid under the Affordable Care Act than those that didn’t, based on Census data and statistics from the Centers for Disease Control and Prevention…
Overall, overdose deaths per million residents increased twice as fast in Medicaid expansion states than in non-expansion states.
Correlation doesn’t automatically equal causation, but Johnson provides reason to think it exists in this case. Based on police comments, he reports someone with a Medicaid card can obtain up to 240 oxycodone pills for as little as a $1 co-pay. Those pills can then be resold for $4,000 on the black market.
It’s not unreasonable to think some people will exploit the system for fast cash, especially since others (taxpayers) foot almost all up-front costs.” (B)

“We need a plan. Now that the President has labeled this as a national health emergency, we need to act on this momentum to effectively combat this crisis….
Addiction is an illness, and we must start treating those struggling with substance abuse like patients.
Part of this approach must include improving access and use of treatment and recovery services, offering support to people who have become addicted, and using research data to prevent high-risk populations from ever encountering opioids. And we need more post-treatment rehabilitation programming that reintegrates recovering patients into society.
And importantly, we need to focus on prevention and improve education and training for the physicians and healthcare professionals who are on the front lines of this crisis. Similarly, we all need to understand the dangers of opioid abuse and the risk of addiction and overdose.
Federal money should go towards funding innovative solutions– (C)

STRATEGIES
“Following on the heels of last week, advocates, social service providers and people with a history of drug use staged a protest on Thursday at the office of Governor Andrew Cuomo to raise the visibility of the epidemic of overdose raging across the state and demand bolder political action.
Protestors called on the Governor to: 1) guarantee universal access to sterile syringes, naloxone, buprenorphine and methadone to every New York State resident struggling with a heroin or opioid addiction; 2) mandate that every Office of Alcohol and Substance Abuse Services (OASAS) funded program at least offer buprenorphine and/or methadone to people using opioids; 3) support the creation of safer consumption spaces, also known as supervised injection facilities.

New York State does need to ensure immediate access to drug treatment on demand for all its residents, but to tackle the overdose crisis it must also ensure that the treatment offered adopts evidenced-based approaches that work. Additionally, many New Yorkers, especially those in rural counties, have limited or no access to proven public health interventions like sterile syringe access, naloxone, buprenorphine or methadone, leading them to continued heroin and opioid use.” (D)

“Physicians are increasingly being asked for pain medication and some struggle to determine how to prescribe appropriately. It may be obvious that a patient needs some pain management after a procedure or while managing a painful condition. And it might be clear that an endless supply of opioids puts a person at high risk for addiction. But how much is enough? How much is too much? Three tablets? Six? 12?…
Practicing Wisely™, a new initiative aimed at developing measures of clinical appropriateness, does just this. States can use the program’s opioid measures to track variation in physician prescribing behavior for specific cases of opioid use, such as prescription rates following a C-Section. Comparing physicians’ prescribing patterns to the prescribing patterns of like-specialty physicians, performing the same procedure on a similar patient population can help to identify physician outliers. That is, physicians whose prescription rate deviates constantly from the rates of their peers for a given type of opioid use. Importantly, physicians can gain insight into how their peers are responding to demand for opioids and can consider any adjustments to their own behavior that might be more in line with what is typical among a similar population.
To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays, and they can tackle the “gray” area of appropriate prescribing through the deployment of appropriateness measures.”(E)

“In the wake of President Trump declaring the opioid epidemic “a national emergency,” Express Scripts, the nation’s largest pharmacy benefit manager (PBM), has rolled out a new opioid management program that will limit the number and strength of opioid drugs to first-time patients…
Express Scripts’ Advanced Opioid Management solution is expected minimize early exposure to opioids while helping prevent progression to overuse and abuse, while ensuring access to medication patients need.
In a pilot study, the PBM observed a 38% reduction in hospitalizations and a 40% reduction in emergency room visits after educating patients about the risk of opioid use. An educational letter was also sent out to providers who showed high prescribing patterns and held counseling calls. Among this subset, a 19% decrease in the day’s supply of opioid dispensing during six-months of follow up, was observed.
Meanwhile, the American Medical Association (AMA) has found fault with the program, saying that treatment decisions should be left to physicians and their patients.
Here are 7 things to know about Express Scripts’ program to limit opioids:..” (F)

“Three local library systems are training staff in the use of the opioid overdose antidote naloxone and others are considering the move as more government agencies are joining the fight against Maryland’s opioid epidemic.
Library staff in Harford, Carroll and Anne Arundel counties have begun to offer training in administering naloxone, also known by its brand name, Narcan.
Meanwhile, library systems across the region are giving patrons access to a database of ebooks, audiobooks and other resources on addiction, recovery and the opioid epidemic, part of an effort to make libraries a greater resource for people confronting drug abuse.” (G)

“Mr. President, if you are serious about stopping America’s opioid crisis, instruct Attorney General Jeff Sessions to have the Department of Justice join in these legal actions, bringing the investigatory and legal weight of the FBI to battle the multibillion-dollar pharmaceutical opioid industry and the largest distributors and retailers of the drugs. Don’t waste federal resources on isolated overprescribing doctors and puny drugstores — the states can handle those cases. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids.
Stop the export of America’s opioid crisis.
Stop the import of fake and copycat foreign-made opioids. “ (H)

“Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.
Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.” (I)

(A) America’s self-inflicted opioid crisis, by Ken Fisher, http://medicaleconomics.modernmedicine.com/medical-economics/news/america-s-self-inflicted-opioid-crisis?page=0%2C1
(B) Government’s role in opioid crisis deserves review, http://newsok.com/article/5560720
(C) Abuse Deterrent Formulations are a Critical Step in Solving the Opioid Crisis, by Doug Schoen , https://www.forbes.com/sites/dougschoen/2017/08/18/abuse-deterrent-formulations-are-a-critical-step-in-solving-the-opioid-crisis/#708e9a174b87
(D) CityViews: Calling Out Cuomo for the Opioid Crisis, By Jeremy Saunders, http://citylimits.org/2017/08/18/cityviews-calling-out-cuomo-for-the-opioid-crisis/
(E) How Medicaid Programs Are Managing the Opioid Crisis, by Parie Garg, http://health.oliverwyman.com/transform-care/2017/08/how_medicaid_program.html
(F) Seven things to know about Express Scripts’ plan to limit opioids, by Tracey Walker, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/seven-things-know-about-express-scripts-plan-limit-opioids
(G) Libraries join opioid addiction fight through Narcan training, by Mina Haq and Jon Kelvey, http://www.baltimoresun.com/health/bs-md-library-opioid-resources-0809-story.html
(H) How Not to Handle the Opioid Crisis, by LAURIE GARRETT, http://foreignpolicy.com/2017/08/22/how-not-to-handle-the-opioid-crisis/
(I) Dying At Home In An Opioid Crisis: Hospices Grapple With Stolen Meds, by Melissa Bailey, http://khn.org/news/dying-at-home-in-an-opioid-crisis-hospices-grapple-with-stolen-meds/

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The PSA experts’ kerfuffle! Is there an evidence-based algorithm?

Recently I was listening to a health call-in show on public radio during which a urologist gave advice on the diagnosis protocol for prostate cancer seemingly different and more aggressive from the one used by my urologist.
I remember when the “gold standard” for PSA prostate screening was a score of 4 or below. Then lost favor and PSA trajectory became the new GS, more specifically and increasing PSA score over time was cause for alarm. It seems that expert advice changes every few years resulting in less guidance on what to do rather than more evidenced-based recommendations.

So I started Googling:
“It can be hard for physicians to follow current thinking of experts on medical care. It must be exponentially harder for the public to make sense of it. Recently, the United States Preventive Services Task Force changed its recommendation on prostate cancer screening from a D (that is, don’t do it) to a C (discuss it with your doctor).”
“Five years ago, the task force gave prostate cancer screening a D recommendation because there are real harms from over-diagnosis of the disease. Over-diagnosis leads to unnecessary treatments, and a newly discovered cancer could lead to no symptoms or harm over the patient’s lifetime. The treatments for prostate cancer, including radiation and prostatectomy, have high levels of adverse events. About 75 percent of all the men treated will have impotence, incontinence or both.”
Further, at the time of the 2012 statement, there appeared to be little evidence that screening with a prostate-specific antigen blood test (PSA) reduced prostate cancer mortality. With no clear benefit, and significant harms, a D recommendation seemed appropriate.
…..I’m sure the nuances of A, B, C and D recommendations can be confusing to the public. They can also make it seem as if experts are constantly changing their minds. But this is how we want our experts to react: When new evidence is found, it should be added to older evidence to change our thinking when appropriate. (A)

CHOOSING WISELY
“For years, doctors have used a PSA blood test to screen men for prostate cancer. The test measures a protein made by the prostate gland, called a prostate-specific antigen (PSA).
But the PSA test can do more harm than good. Here’s why: The test is often not needed.
Most men with high PSAs don’t have prostate cancer. Their high PSAs might be due to: An enlarged prostate gland; A prostate infection; Recent sexual activity; A recent, long bike ride.
Up to 25% of men with high PSAs may have prostate cancer, depending on age and PSA level. But most of these cancers do not cause problems. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. They are not likely to spread beyond the prostate. They usually don’t cause symptoms, or death.
Studies show that routine PSA tests of 1,000 men ages 55 to 69 prevent one prostate cancer death. But the PSA also has risks.
There are risks to getting prostate cancer tests and treatments…” (B)

When is a PSA test needed?
If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits.
Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.
You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.(C)

Talk to your urologist about Watchful Waiting and Active Surveillance
“Active surveillance is often used to mean monitoring the cancer closely. Usually this approach includes a doctor visit with a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) about every 6 months. Prostate biopsies may be done every year as well. If your test results change, your doctor would then talk to you about treatment options.
Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.”
“One of these approaches might be recommended if your cancer: Isn’t causing any symptoms; Is expected to grow slowly (based on Gleason score); Is small; Is just in the prostate…
Watchful waiting and active surveillance are reasonable options for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments to try to remove or destroy the cancer.” (D)

I f you wind up having a biopsy, consider getting a second opinion before starting one of the various therapies available.
Options include: Surgery. Radiation therapy. Cryotherapy (cryosurgery). Hormone therapy; chemotherapy; Vaccine treatment; Bone-directed treatment (E)

And always keep your primary care physician involved, the doctor who knows you best.

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) The ABCs and Ds of Whether to Get Prostate Cancer Screening, by Aaron E. Carroll, https://www.nytimes.com/2017/06/26/upshot/the-abcs-and-ds-of-whether-to-get-prostate-cancer-screening.html
(B) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(C) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(D) Watchful Waiting or Active Surveillance for Prostate Cancer, https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html
(E) Treating Prostate Cancer https://www.cancer.org/cancer/prostate-cancer/treating.html

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