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The CMG Voice

The number of hospitals is shrinking.

Posted Monday, March 12, 2018 by Tyler Goldberg-Hoss

Recently I read an opinion piece in the New York Times by oncologist and bioethicist Ezekiel “Zeke” Emanuel, M.D., regarding the role of hospitals in our health care system. Dr. Emanuel posited that hospitals are shrinking in number, and that trend is a good thing for patient safety and cost.

It is an interesting read. Dr. Emanuel describes the rise of hospitals in the late 19th century, particularly with the advent of safer surgical technique, the discovery of x-ray technology, and a better understanding of how to reduce the spread of infectious disease. The amount of hospitals and hospitalizations grew until reaching a zenith in 1981.

Since that time, while the population has grown, the number of hospitalizations has decreased. This in part is because much care now does not necessitate hospitalization, such as chemotherapy, joint replacement surgeries, and even births.

And this may be a good thing. Dr. Emanuel points out that in 2002, there were nearly 1.7 million hospital acquired infection causing approximately 100,000 deaths. Further, a hospitalization is better characterized as a “trial to be endured” than “rejuvenating stay at a spa”.

Certainly, hospitals will not like it if this trend continues. In the Pacific Northwest, we have already seen hospitals merge with one another, ostensibly for purposes of saving money. However, as a recent lawsuit filed by Washington’s AG against Catholic Health Initiatives d/b/a Franciscan Health System and other health care entities in Kitsap County shows, such mergers and relationships risk raising consumer prices.

You can read Dr. Emanuel’s full opinion piece here:

Are Hospitals Becoming Obsolete?

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What’s in your IV bag? Should it be?

Posted Friday, March 9, 2018 by Tyler Goldberg-Hoss

Recent studies published by the New England Journal of Medicine conclude that “balanced crystalloids” should replace saline as liquid of choice in IV drips for patients.

If you have spent much time in a hospital setting (or watched a hospital-based TV show), you know what an IV drip is: a bag of liquid solution hanging from a pole, with a line down to the patient to deliver the contents of the bag. IVs are used to increase fluids in a patient who may be becoming dehydrated, or to give a patient nutrients or medicine.

Saline – essentially salt dissolved into water – is routinely used in IVs. However, this new research tells us that saline, and particularly the salt in it, is causing a lot of kidney damage. So much, that the researchers estimate switching from saline to balanced crystalloids could save 50,000-70,000 lives and prevent 100,000 cases of kidney failure in the US each year.

The studies involved patients at Vanderbilt, and after the results were known, Vanderbilt itself decided to switch to primarily using balanced crystalloids in their IV bags. Countries in Europe and Australia have already made the switch.

For further reading, an abstract of the results of the studies can be found here:

Balanced Crystalloids versus Saline in Critically Ill Adults

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Should the US consider an “opt out” system for organ donation?

Posted Monday, March 5, 2018 by Tyler Goldberg-Hoss

Typically in the United States, the idea of organ donation occurs at some point when you interact with your state’s Department of Licensing. If you agree (opt in) to organ donation, you have a little red heart on your driver’s license.

Unfortunately, there appears to be a long-standing problem of too few organ donations for the people who need them. Recently, one count estimated the number of people in the US waiting for organ transplants at over 115,000. Regularly, such people waiting for a life saving transplant die before getting one.

Although some folks have argued for allowing for the buying and selling of organs, it is expressly against the law in the US – you can get 5 years in jail for doing so. So without a market place for organ procurement, and without enough donors to meet supply (and with the number of available donors likely to shrink in the coming decades after driverless car technology is perfected, and there are far fewer vehicular fatalities to produce viable organ donations), some countries have decided to change “opt in” systems to “opt out” systems.

Simply put, with “opt in” systems the default is that you are not an organ donor – you must affirmatively decide to be a donor. But with “opt out” systems, the default is you are an organ donor, and you must affirmatively opt out.

Currently there are over two dozen European countries with some form of an “opt out” system. Recently a couple of states introduced such legislation, but neither became law.

The system – particularly in a country such as the United States which very much values a person’s autonomy and freedom (“Don’t Tread On Me”) – many can be persuaded by the argument that an “opt out” system is allowing the government too much control over a person’s body.

But in the context of so many people dying waiting for transplants, perhaps it is time to consider a new strategy.

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JAMA releases guidelines for what doctors should know about weight loss supplements.

Posted Thursday, March 1, 2018 by Tyler Goldberg-Hoss

If you have recently visited your local pharmacy, you may have come across the shelf (or shelves, or aisle, or aisles) of supplements geared at weight loss. There are so many different supplements – promising to do many different things – that it can be difficult for a physician to counsel his or her patient about using them. And there are so many people using these supplements – by one count more than half of adult Americans have used one such product.

The Journal of the American Medical Association (JAMA) recently set out guidelines for doctors regarding their patients’ use of vitamin and mineral supplements. Although the guidelines do not attempt to analyze the merits of using any particular supplement, they do group each supplement by category, and within each category define the possible issues associated with taking the supplement.

This guidance appears to be a useful tool for clinicians in addressing this with their patients, as it gathers in one place the recommendations from different sources in one convenient location.

If you have any questions yourself about what the guidelines say about how such supplements may affect you, you can read here:

Vitamin and Mineral Supplements - What Clinicians Need to Know

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How will we address the health of our aging population? Look into the future by looking at Japan.

Posted Monday, February 26, 2018 by Tyler Goldberg-Hoss

A country is defined as “super aging” if more than 20 percent of its population is 65 or older. While the United States is not there yet, it is expected that we will be in another 40 or so years.

Given the current state of our health care system, how might we begin to address the increased burdens on it as we age? We might learn a thing or two from how Japan is doing it, and in particular how it is experimenting with technology and the well being of its elderly citizens.

The Japanese government has invested millions in this research. In one area, a bot named Palro helps to keep Japanese seniors engaged and happy, as a dancer, exercise instructor or performer. Japan is also experimenting with Virtual Reality (VR) and how it may be used.

The future is exciting and scary, but Japan’s work in this area makes it more palatable to envision.

You can read more about this here:

Watch: Japan faces its old age with robots and virtual reality

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