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The CMG Voice

In home primary care visits hope to improve health care, save money

Posted Tuesday, January 30, 2018 by Tyler Goldberg-Hoss

As many of us know, health care in our country is not perfect. One problem involves access to primary care, and the corresponding problem of people with non-emergent health care needs resorting to the local emergency department for help.

Concurrently, there has been an increase in the availability and use of technology in health care, including telemedicine – the ability to provide care to patients remotely. This has been the subject of recent blog posts here and here.

In this context, a community health center in Washington, D.C. has started a pilot program which brings primary care services to the homes of folks who can’t or won’t make it to primary care visits, and who are risks to use the local ER instead.

As described in a recent NPR article, a medical assistant goes to a patient’s home with a suitcase full of equipment to check his vital signs, and with a laptop which connects virtually with a doctor in another part of town. The medical assistant takes and records the patient’s blood pressure and pulse, weighs him, and listens to his lungs. While this is going on, a doctor is “seeing” the patient through the laptop, considering the new vital signs, and recommending treatment.

The purpose of such programs is at least two fold. First, health care organizations want to figure out a way to provide preventative care services to patients who either can’t make such visits (whether due to mobility, work, childcare, or some other reason). Offering in home telemetry-based services will hopefully make the population healthier.

Second, it will save money in the long run, not only as a result of a healthier population, but also with a reduction in the amount of non-emergent ER visits.

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Americans have low opinion of health care offered, ability of government to fix it

Posted Thursday, January 25, 2018 by Tyler Goldberg-Hoss

A recent poll found that 48% of Americans named health care as the top problem for the government to focus on in 2018. However, of those who named health care the top problem, 70% of them had little to no confidence that government will make improvements.

Reasons for dissatisfaction include particularly the cost of insurance and what that insurance actually covers. Many Americans still cannot afford even the most basic plans, and those who can afford a plan often need procedures that are not covered by it.

You can read an article on this new poll here:

In new poll, health care is the issue that won’t go away

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Drug overdoses bring life expectancy down in US for second straight year

Posted Monday, January 22, 2018 by Tyler Goldberg-Hoss

Recently released government figures show, for the second year in a row, that the life expectancy of an American is lower than it was the year before.

The culprit: drug overdose deaths, particularly involving opioids. As has been reported in recent blog posts, the opioid epidemic is continuing to ravage communities across the country, with municipalities in recent months filing lawsuits on behalf of their communities against both the maker of the medications and also, in at least one circumstance, the commission responsible for overseeing the safety of patients and medications.

Of note, usually when life expectancy dips down one year it rebounds the next. The last two year drop was in 1962-63, and the last time there was a three year decline was in 1916-1918 during the worst flu pandemic in modern history.

You can read more about this here:

Soaring overdose deaths cut U.S. life expectancy for 2nd straight year

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Are Medical Tests Useful? Not Necessarily.

Posted Friday, January 19, 2018 by Gene Moen

Dr. James Salwitz recently wrote a blog post about the tendency of doctors to over-test. He pointed out that ordering myriad tests will not necessarily provide for better medical care. The worst example, he wrote, is the ordering of an invasive test where the results won’t change what will be done to help the patient.

He cites an example of an 89-year old patient in whom lung nodules were found in a chest x-ray, probably from cancer metastasis. The doctor recommended a biopsy. When the patient asked what would happen if they proved to be cancerous, the answer was, of course, expensive and debilitating treatment that might prolong her life for a short while — or might not. The patient declined.

He blames part of the tendency to over-test for unlikely or extraordinarily rare conditions on the personality characteristics of doctors, coupled with their training. Physicians want to have a standard of exactitude, which is often not reasonable or practical. He writes “[doctors] stay awake at night because of a small probability that an obscure diagnosis might be missed because blood was not drawn, an x-ray not taken, or an orifice not invaded.” There is a tendency to expand the differential diagnosis to include diseases whose likelihood is remote.

The question that should be asked, says Dr. Salwitz, is: will the test results likely change the care that is provided?

In cases where patients are already very ill with a particular disease, should doctors be looking for other disease conditions? Dr. Salwitz cites the example of a patient with lung cancer, who presented with symptoms that might indicate unstable heart disease. So a cardiac catheterization was performed, with the result that the intravenous dye caused him to have sudden kidney failure. Dr. Salwitz points out that, before they invaded his heart and damaged his kidneys, they should have asked “Are we going to fix the coronary arteries of a patient with advanced lung cancer?”

Dr. Salwitz decries the tendency, often pushed by relatives, to continue to order x-rays and labs, even though the medical condition of the patient is beyond remediation. Intrusive testing, rather than comfort control, is the theme.

Rather than assuming that more tests are better, he says it is better to have a clear understanding of how a particular test is going to change the care plan. “A test only has value if it improves life.”

In his article, Dr. Salwitz does not comment on the dilemma of whether tests results are certain enough to justify changes in medical care. Examples are recent recommendations to pull back from routine breast imaging and PSA test reliance, because so often the results of false positives — expensive and often dangerous treatment — may outweigh the benefits of diagnosis.

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Alright, Once Again: Is Coffee Good Or Bad For You?

Posted Tuesday, January 16, 2018 by Gene Moen

Not a week goes by when we don’t hear information about certain foods or other substances hurt or help our health. Coffee and alcohol are the big ones, with some articles warning us about too much or too little of either. The latest research, from England, was reported in November, 2017 in MedPage Today. The overall conclusion was that daily consumption of coffee is not only safe, but likely to benefit health.

The research analyzed more than 200 studies, and the researchers concluded that drinking three or four cups of coffee a day reduces overall mortality, cardiovascular mortality, and cardiovascular disease. In addition, the studies showed a reduced incidence of cancer, and a lower risk for non-alcoholic fatty liver disease, liver fibrosis, and liver cirrhosis as well as type 2 diabetes and Alzheimer’s disease.

The numerous studies that were analyzed found no consistent evidence of harmful effects from coffee consumption, except for some related to pregnancy and fracture risk in women. Coffee consumption was associated with low birth weight, preterm birth, and pregnancy loss. In women there was an association between age and coffee consumption in terms of risk of fracture.

The authors of the meta-analysis cautioned that much of the evidence cited in the studies was low quality. Randomized trials may be needed to be more certain about the health impact of caffeine consumption, but the high cost of such studies coupled with the large sample size required may complicate the possibility of doing such studies. Nonetheless, the analysis seemed to support that coffee consumption, possibly optimized at 3-4 cups a day, is unlikely to result in significant harm to those who indulge. Good news for Starbucks!

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