Medical Economics

Kicking Hepatitis C Down The Road

Hepatitis C has exposed one of the larger cracks in American healthcare financing. In particular, the drug Harvoni (ledipasvir-sofosbuvir) has shown us the inherent conflict between private health insurance (commercial insurance companies) and public health insurance (Medicare, Medicaid, etc.).

Hepatitis C is an enormous problem in the United States. There are about 2.7 million Americans with chronic hepatitis C – thats 1% of our population. Worldwide, there are about 200 million people infected with the virus. It is the #1 cause of liver transplant in the United States and it causes around 10,000 deaths per year. Half of the people infected don’t know that they are infected and there is no vaccine to prevent it. The most recent cost estimate for the virus in the United States is $6.5 billion per year. That is $21 for every man, woman, and child in our country. In other words, this is a big public health problem and big cost to our nation.

But things are changing for hepatitis C. Patients can now be essentially cured of the infection with Harvoni. The problem is that Harvoni costs $90,000 for a 12-week course.

So, here is what happens. A person acquires hepatitis C as a relatively young adult (when they have commercial insurance) and then the hepatitis C manifests itself 20-40 years later with cirrhosis or hepatocellular carcinoma as an older adult (when they have Medicare).

The commercial insurance company is financially motivated to prevent conditions that would arise when a person is relatively young and still covered by that insurance company, because those conditions are costly to treat. Therefore, it is cheaper for the insurance company to prevent a disease that is going to show up in 3-4 years than to have to treat that disease 3-4 years later. A example of this is an insurance company paying to treat high cholesterol with a statin in a 40-year old so that they don’t have to pay for the person’s myocardial infarction when they are 44-years old.

For hepatitis C, the insurance companies have little financial motivation to treat since the company isn’t going to be paying for the liver transplant or hepatectomy when the disease finally manifests itself – Medicare will. The insurance company is incentivized to get you to 65 without any expensive medical problems. There is no incentive for anything that happens to a person after age 65 – that’s Medicare’s problem.

On the other hand, Medicaid is incentivized to treat hepatitis C. The prevalence of hepatitis C is 7.5 times higher in the Medicaid population than in the commercially insured population and persons with hepatitis C on Medicaid are much younger than those who are commercially insured. Medicaid’s goal is to keep the person healthy enough that they can eventually become gainfully employed and therefore get off of Medicaid and onto a commercial health insurance plan. If that person develops cirrhosis, they likely won’t be working and will stay on Medicaid until they die, racking up higher costs for Medicaid.

Somehow we need to change the incentives so that all insurers are motivated to keep people healthy not just to age 65 but beyond. This will not only ultimately reduce healthcare costs in the United States by reducing the costs incurred by older Americans covered by Medicare but it will also keep Americans healthy enough that they can continue to work after age 65 which will reduce poverty among older Americans and put less financial burden on our nation in the form of Social Security. When the commercial insurance company denies coverage for Harvoni, it is not because the insurance company doesn’t think Harvoni will improve your health, it is because by not covering it, it will improve the company’s financial health.

We as Americans like to think that we have the best healthcare in the world. And as a Cleveland Brown’s fan, I keep thinking that this year we’re going to have a winning season. Somehow, reality always catches up.

November 3, 2016

Procedure Areas

The Dialysis Blues

dialysisEnd-stage renal disease has been driving me crazy recently. When no one else will dialyze you, the hospital has to. There’s this thing called EMTALA law that requires us to treat you if you show up in our emergency department. Let me tell you about a few of our more exasperating patients that could fill out the entire cast in a theater of the absurd. In order to prevent being presented with a subpoena from the HIPAA police for violating patient confidentiality, I’ve made a few changes to the details, but not too many.

First case is a lady who decided that what she really wanted from Santa for Christmas was a new Glock handgun. The perfect fashion accessory for the woman who has everything. She was really proud of it so she showed it off to all of her friends at her dialysis center. The problem is that the dialysis center had a zero tolerance policy for patients bringing in hand grenades, surface-to-air missiles, nuclear bombs, and other weapons into the dialysis center. So she was banned for life from returning. Because she still needed dialysis that day, she came to the emergency department and got admitted. And we dialyzed her. And for a hospital, once you dialyze a patient, you own them forever. So it became our problem to arrange for regular 3-times a week outpatient dialysis. But the word got out and none of the other dialysis centers in town would take her. So, we were stuck with doing her dialysis. But the problem is, we are certified as an inpatient dialysis unit and not as an outpatient dialysis unit. Therefore, her insurance company said that the only way they would pay us to dialyze her was if she was an inpatient.  So, rather than having her just show up 3 days a week in the dialysis unit, get dialyzed , and go home, we had to admit her. The problem is that the insurance company wouldn’t pay for an elective hospitalization for renal failure, only an emergency hospitalization for renal failure. The only way we could get paid was to have the patient come into the ER, be seen by the ER physician, get labs to prove that her potassium was too high and her bicarbonate was too low, get admitted to the hospital, have a resident do an H&P and admission orders, get a nephrology consult, get dialyzed, and then have the admitting service do a discharge summary. Fortunately, after a couple of months, one of the private dialysis centers came through and accepted her… but only after we had proven that she wasn’t packing a gun any more by going through the metal detector in the emergency room every Monday, Wednesday, and Thursday for 8 weeks.

Second case is a guy from Nicaragua who decided to come visit his son in the United States. The only problem was, he didn’t have a passport. And his kidneys didn’t work. So, he jumped the fence in Texas and hitched a ride to Central Ohio. A couple of months later, he ended up in our emergency room with uncontrolled hypertension and kidney failure. We dialyzed him… and then we owned him. He got a dialysis access fistula but since he was an undocumented foreign national (the politically correct term for illegal immigrant) with no health insurance, no dialysis center would take him. And so now he comes into the ER every Tuesday and Friday and gets dialyzed. He needs medications for his blood pressure and his other medical problems but he can’t afford to buy them so he doesn’t take them. It turns out that this is not such an infrequent occurrence. What one of the private hospitals in Columbus does is when they get a patient like this, they don’t want to have to mess with doing the dialysis so the hospital actually pays a private dialysis center to do the dialysis. A hospital in Chicago tried to deal with a similar situation by arranging for their patient to be deported but there was such a public opinion outcry that they backed off. Since we are a State hospital, we can’t pay for a private dialysis center to do dialysis on an undocumented foreign national (lest it be perceived we are using taxpayer dollars to pay someone to dialyze an illegal immigrant) and we don’t want to risk the public relations nightmare of deporting someone’s poor grandfather because we won’t treat his medical problems.

The third patient got off of a plane at John Glenn International Airport after a long flight from Kenya. She hopped in a cab and came straight to our emergency department because she needed her regular dialysis. It seems that she sort of forgot to check the box on the visa form about having end-stage renal disease and needing dialysis three times a week. She wasn’t going to get back on the plane so we admitted her and dialyzed her… and then we owned her. Fortunately in her case, a local church group raised dialysis money and one of the local private dialysis centers took her on a cash basis.

In these situations, no one wants to pay for the dialysis for these patients. So what happens? We all pay for it. Because even though our hospital covers the cost of dialysis, we do it using the margin that we make from all of the insured patients, Medicare patients, and Medicaid patients that come through our doors. And it is the same for every patient that we take care of who is uninsured. Their care is paid for by everyone who pays payroll taxes and health insurance premiums. So when we dialyze them, American owns them.

November 2, 2016

Inpatient Practice

The Most Dangerous Procedure In Medicine

danger-signAlright, from the title of this post, I’m sure you are trying to guess what it is. Open heart surgery? A craniotomy? Separation of conjoined twins? Wrong. The most dangerous procedure in medicine is the hospital discharge.

From the time a patient is admitted to the hospital, the medical resident or the hospitalist has one mission – to get that patient discharged, preferably alive. That’s because the discharge is the ultimate goal of a patient’s hospitalization.

We are singularly focused on discharge. As soon as a patient hits the nursing unit, we are pressing the admitting physician to enter a projected discharge date so that the hospital’s case management machinery can start working to get that patient out of the hospital. We analyze hospital length of stay for each physician, rewarding those who keep their length of stay index below one and chastising those with a length of stay index greater than 1. We put enormous resources into getting discharges out of their hospital room by noon so that we can make room for the next patient.

So why aren’t we patting each other on the back for every hospital discharge, after all, the fact that the patient is being discharged means that they are getting better so we were successful, right?

The problem is that there is so much that can go wrong when we discharge a patient. Here are just a few of them:

  1. Medication reconciliation. Everybody talks about it but nobody does it very well. In order to keep our hospital costs down, we have a relatively limited number of medications in our hospital pharmacy formularies, limited to those drugs in each category that we are able to get the best pricing on. The problem is that these are not the drugs that the patient will be taking at home which are dictated by their insurance company’s formulary. And so the drug that the patient got better taking in the hospital is often different than the drug that the patient will pick up at the drug store. Even more of a problem, the patients frequently assume that they are supposed to take both the drug that is on their hospital discharge instructions and the drug that their primary care physician had prescribed for them prior to their hospitalization. I can’t even count the number of times that one of my patients who had been taking Advair for years comes into the office after a hospitalization taking both Advair and Symbicort because Advair wasn’t on the hospital formulary and the hospitalist put them on the equivalent Symbicort when they were in the hospital.
  2. Medication access. This has gotten a little better as patients have had better access to health insurance under the Affordable Care Act. But it is still common for a drug to be prescribed at discharge from the hospital that the patient can’t afford once they go to pick it up at their local pharmacy. So what do they do when faced with a bill for a $300 antibiotic? They don’t buy it. And then they get sick again.
  3. Nursing & doctor care. When they are in the hospital, patients are getting vital signs every 6 hours and seeing the hospitalist once or twice a day. As soon as they leave, that changes to seeing their primary care physician 3 weeks from now. We monitor patients up the wahzoo in the hospital and then release them into the wild the minute that they walk out the door.
  4. Oxygen. This one is a pet peeve of mine, as a pulmonologist. We check the patient’s oxygen saturation by oximetry every day or multiple times a day in the hospital – almost always when they are resting quietly in bed. But they are not resting quietly at home, they are walking around, climbing stairs, carrying groceries, etc. And their oxygen saturation is a lot different when they are doing those activities. I’m always dismayed when a patient shows up in the office for their hospital follow up and the nurse checks their oxygen saturation right after they walk 50 feet from the waiting area to the exam room and the saturation is 76%. When you go back to the hospital record, it was always in the 90’s because it was always measured after the patient had been lying in bed for an hour.
  5. Medical follow-up. If a patient gets discharged on a Saturday morning, the case managers (if they are even in on Saturdays) can’t schedule a follow-up office visit with the patient’s primary care physician. So instead, the discharge instructions will typically say something like: “Please call your primary care physician’s office on Monday to make an appointment to be seen within 3 days.” Here’s what usually happens: the patient forgets to call, the physician is out of town for 2 weeks, the physician doesn’t have any available appointments until December, or the patient doesn’t even have a primary care physician.
  6. Communication with the outpatient physician. So lets be optimistic and the patient does call and get an appointment to see his primary care physician the next Tuesday. He shows up and his doctor asks him why he is there. The hospital policy is that a discharge summary has to be dictated within 5 days of discharge and the hospitalist hasn’t gotten around to dictating it yet. The patient says he was in the hospital because of high blood pressure. The primary care physician checks his blood pressure and it is normal so he sends the patient out. Two weeks later, when the discharge summary finally arrives in the mail, it says that the patient was admitted with hypertension and chest pain and was found to have an ejection fraction of 15%, an aortic dissection, and syphilis and that he should see his PCP for treatment.
  7. Diet. No human being ever gets put on a regular diet in the hospital. It is usually some combination of low salt, carbohydrate limited, caffeine-free, diabetic no added sugar, 15 gram protein diet. Its no wonder they all hate our hospital food, its nothing like what they eat at home. And so the patient with heart failure goes home and what’s the first thing he does? Open up his pantry and pull out a jumbo bag of Doritos and then wash it down with a liter of original Coke. When you ask him about it the next day when he’s back in the emergency department, he’ll tell you quite honestly that the discharge instructions didn’t say anything about avoiding Doritos.
  8. Pending tests. As soon as a patient is out of sight, they are out of mind. And so the chest CT scan result that was pending at the time of diagnosis comes back showing a “large lung mass that should be considered lung cancer until proven otherwise”. But the patient is gone so nobody sees the report. Or maybe the final culture from the bronchoscopy that the pulmonologist did comes back with Cryptococcus. But the report goes to the hospitalist who doesn’t know what Cryptococcus is and assumes it must be a part of normal flora.

There are a thousand things that can go wrong when a patient gets discharged. And that’s why the discharge is the most dangerous procedure in medicine.

October 31, 2016

Inpatient Practice

The Documentation Game

board-gameOur hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well. If the hospital mortality index is 1.0, that means that you had exactly the number of inpatient deaths that other hospitals have on average, after those patients are adjusted for their case mix index (CMI; a way of quantifying how sick the patients are). If your mortality index is > 1.0, then you had more deaths than the average hospital and if it is < 1.0, then you had fewer deaths than average. Another way of stating this is that the mortality index is the ratio of observed: expected mortality. At 0.54, our mortality index is one of the lowest of all hospitals in the country.

There are two ways you can keep your mortality index down: you can have few deaths (observed mortality) or you can document that you take care of a lot of sick patients. The best performing hospitals do both. As an example, your mortality index will be high if you have a young patient who came in for an elective cholecystectomy die (low expected mortality). On the other hand, if you have a 90-year old who has leukemia, is in heart failure, and is on dialysis come in for an emergent appendectomy and he dies (high expected mortality), your mortality index does not go up so much.

So if you want to be a best-performing hospital with a low mortality index, it is not good enough to just take great care of your patients, you have to document how sick they are. That’s where documenting secondary diagnoses that are present on admission becomes critical… and that’s where most physicians fall short. The hospital coders have to be able to pick those diagnoses out of the admission history and physical examination so it is necessary that the history and physical exam contain the precise words that indicate those secondary diagnoses that can significantly impact the case mix index. Words matter: you can’t just write “potassium = 3.0, will give KCl”, you have to actually write “hypokalemia, will give KCl”.

Here are the top secondary diagnoses that affect the expected mortality score:

  1. Anemia (specific type of anemia and whether it is acute or chronic)
  2. Acute respiratory failure
  3. Coagulopathy (including use of anticoagulants)
  4. Heart failure (systolic or diastolic; acute or chronic)
  5. Chronic kidney disease (including the stage number)
  6. End-stage renal disease
  7. Diabetes (including whether it is type I or type II, controlled or uncontrolled, and what organs have manifested complications)
  8. Hyperkalemia
  9. Hypokalemia
  10. Hypochloremia
  11. Hypomagnesemia
  12. Hypophosphatemia
  13. Hyperphosphatemia
  14. Hypocalcemia
  15. Hypercalcemia
  16. Hyponatremia
  17. Hypernatremia
  18. Dehydration
  19. Hepatitis (A, B, or C; acute or chronic)
  20. Liver disease
  21. Protein calorie malnutrition (mild, moderate, or severe)
  22. Metastatic cancer (including what organ it metastasized to)
  23. Decubitus ulcer (including the stage number)
  24. Pleural effusion
  25. Pulmonary edema
  26. Neurological or brain/spinal conditions
  27. Sepsis
  28. Shock
  29. Transfer from an acute care setting
  30. Requiring mechanical ventilation

We were all trained in medical school that the history and physical examination was all about our diagnostic impression and medical management. But the H&P is additionally an integral part of the documentation game. In the documentation game, the physicians are the players for the hospital and the physician gets more points for the more secondary diagnoses he or she documents. The winner is the hospital that documents that its patients are really, really sick and then discharges them alive.

October 29, 2016

Life In The Hospital

Electronic Medical Record Translation Guide

For those of you who are new to electronic medical records, you will be learning a new language used by physicians who use electronic medical records. This quick guide will help you translate into English:

When the physician says:        The physician means:

@*#$(^*@                             Would you be so kind as to help me route this encounter?

*$@!!($##*                             I find the communication management function to be satisfyingly easy to use.

)#@@**&!                             Pardon me but could you please assist me in unburdening my inbasket with several of these fascinating communications?

*@##@#!!                              I woke up last night and was unable to fall back to sleep since I was giddy with excitement looking forward to come in to work and use the electronic medical record this morning.

*#^%@*$$                             So sorry, but I appear to have used excessive force on my return button; could I impose upon you to replace my keyboard?

/#**!!@*!                                The beautifully flowing prose that I am able to now create using the electronic medical record is like poetry and brings tears to my eyes every time I read my own progress notes.

#!**@#!?$                              While I was working on my SmartPhrases, my coffee mug has inexplicably been found to be protruding from my monitor screen.

&%@#!*!!#                            My computer seems to have fallen out of my window; might you obtain a new one for me?

!*#@!&^!**                            I dearly love this new system and I am so appreciative that I no longer have to dictate my letters.

October 27, 2016

Life In The Hospital

Necktie, Vector Tie

necktieIf you know me, then you know that I usually don’t wear a tie at work. For most businessmen, a tie is a necessary fashion accessory to the male work wardrobe. For me, it is a device to transfer bacteria from one to another patient.

Studies have shown that 50% of physician’s ties are contaminated by potentially pathogenic bacteria, like methicillin-resistant Staphylococcus aureus (MRSA). They dangle in all kinds of stuff when we lean forward to examine patients and we almost never clean them (come on guys, when was the last time you dropped off a couple of dozen ties at the dry cleaner?). In the United Kingdom in 2007, many hospitals took the issue of physician’s neckties to heart and prohibited them from being worn in the hospital. So why do we keep wearing them?

The men’s necktie has its origins during the 1600’s when Croatian mercenaries working for the French army during the Thirty Years’ War had a habit of knotting a handkerchief around their necks. The French picked up on it and called the knotted cloths “Croats” which got turned into “cravats”, King Louis XIV took it one step further and knotted a piece of lace around his neck and like wildfire, it became the rage all across Europe. The necktie as a fashion statement stuck and we’ve been wearing them ever since.

But neckties can do bad things to you. If they are too tight, they can make your glaucoma worse. If they get caught up in a piece of machinery, they can strangle you. And if someone wants to do you harm, grabbing you by the tie is a really easy way to do it (probably why then NFL dropped the necktie from the game-day uniform of running backs).

In our hospital, we require anyone going into and out of a patient room to sanitize their hands with alcohol hand sanitizer that we keep on the corridor walls every 10 feet or so. But so far, we haven’t invented necktie sanitizers to use after patient encounters.

Personally, I never got the whole necktie fashion thing. I always thought that they were kind of uncomfortable and were always getting in my way. So when I read the recent articles on bacterial colonization of physician ties, I rejoiced because I now finally have an excuse to not wear a tie to work.

October 23, 2016

Emergency Department

Guns, Guns, Guns

gunYesterday, a man was shot a couple of miles from our hospital. Not an unusual event, people get shot every day in America’s large cities. Our hospital is not a designated trauma center but we still have gunshot victims dropped off at our front lobby by their friends – either they die in our ER or we stabilize them and send them to one of the regional trauma centers in Columbus. Guns are a way of life in our city, as they are in all cities in the U.S. We require all patients to go through metal detectors to get into the emergency department – as do all hospitals in town – and finding guns is not uncommon at the metal detector. We require anyone with a weapon to hand it over to our security personnel until they leave – a lot like an old west saloon.

Shootings and murder are commonplace in the United States. We kill each other more than any other first world nation and we are right up there with third world countries where a murder doesn’t even make headlines. We’re pretty good at the detective work that goes into solving those murders, our problem is that we just have too many of them.



To kill a person, two things have to happen. There has to be someone who wants to kill someone else and they have to have an effective way of killing. So, if killing another person requires both intent and an available method, which of these is the reason for the United State’s exceptionally high murder rate compared to peer countries? I’d like to think that it is not because Americans are full of more hatred than other industrialized nations.

A gun is a highly effective way to kill someone and we have too many of them. Guns are everywhere in the United States. We have more guns per capita than any other country on earth. In fact, we have more guns than we have people in our country.


What is the answer? I’m not any smarter than anyone else. But solutions need to start with what we agree on instead of starting with what we disagree on.

I think everyone in the U.S. would agree that a person shouldn’t be able to walk into a sporting goods store and by a nuclear weapon. But almost everyone would agree that a person who wants to go duck hunting should be able to buy a shotgun.

Everyone would agree that someone who was previously convicted of felony armed robbery and is also a card-carrying member of a terrorist group should not be allowed to buy guns. But almost everyone would agree that a law abiding citizen with no criminal record should be allowed to buy a gun.

We agree with the extremes of gun control. What we disagree with is where the line needs to be drawn in the middle. By spending all of our political energy on fighting each other in courts and legislatures about exactly where that middle line is for gun control, we’ve accomplished almost nothing. If we instead started with the fringes of the gun control debate and tried to figure out on what we can agree on, we might actually get something accomplished.

Don’t get me wrong. I’m not a raging liberal out to pry guns from everyone’s hands. I used to be a member of the NRA (when I perceived it as being an organization primarily dedicated to gun safety and recreational hunting rather than a lobby group for gun ownership). Some of my fondest memories from childhood were bird hunting with my father in early winter in rural Southern Ohio. And I’ve personally annihilated hundreds of clay pigeons over the decades (with permanent tinnitus as evidence).

But having too many guns and putting them in the hands of the wrong people just creates a lot more work for all of us who keep America’s hospitals working. As it is right now, we just make it too easy to kill each other in our country. For most of Americans, the topic of gun control is polarizing. But if you work in an emergency department or a trauma operating room, the lack of gun control is just exhausting.

Sorry to be up on a soap box about this. But we have to make steps to stop our country from being the murder capital of the Western World. I would much prefer my hospital to focus on treating disease than treating the consequences of motive + opportunity.

October 18, 2016

Life In The Hospital

The Sports Page

reinikka_reading_the_newspaperLast week, we filmed one of Ohio State’s MedNet-21 webcasts, this one on Environmental Emergencies. One of the topics was hypothermia and one of the presenters, Dr. Nick Kman from OSU, made the comment that “a hypothermic patient is not dead until they are warm and dead”. That reminded me of when I was taught that a patient is not dead until you read the sports page.

I was a 4th year medical student and was doing a rotation in general internal medicine with Dr. Bob Murnane who was a very highly esteemed internist in private practice in Columbus. He had an old-school medical practice: he had a solo practice, his office was across the street from the hospital, and he took care of all of his admitted patients on his own service in the hospital.

One morning, I arrived at his outpatient office. His nurse said Dr. Murnane was over at the hospital after getting stat-paged about one of his patients who had just taken a critical turn. He had told the nurse that we should get over to the patient’s room right away. The other medical student and I ran across the street, ran up the stairs and burst into the patient’s room, both of us out of breath.

We were expecting resuscitation efforts to be underway but when we opened the door, there was Dr. Murnane sitting in a chair in the patient’s room, calmly reading a newspaper. On the other side of the room, laying in bed, was the patient, an elderly lady with advanced dementia who had been admitted with pneumonia. And she looked, well… dead.

Without putting down the paper or looking up, Dr. Murnane said, “sit down boys, it’ll be a few minutes yet”. So we sat down and for about 5 minutes, there was not a sound in the room, except for Dr. Murnane turning the pages of the sports section of the morning newspaper. Finally, he put the paper down, walked over to the patient’s bed, checked her pulse, and said “Yep, she’s dead”.

He went on to say that he never pronounces a patient dead until he reads the sports page.

It turns out that a couple of decades earlier, he pronounced a patient dead who didn’t appear to be breathing and didn’t seem to have a pulse but after the patient had been taken to the morgue, he sat up, very much alive wanting to know why he wasn’t in his hospital room. So ever since, whenever a patient seemed to be dead, Dr. Murnane would check for a pulse and check for spontaneous breathing. Then he’d sit down and read the sports page and when he got done, if the patient still didn’t have a pulse or respirations, then he’d pronounce him dead.

Well, I thought that was just another idiosyncratic Murnane-ism until 4 years later when I was a pulmonary fellow in the MICU. We had a patient with severe COPD who had respiratory failure and was on a ventilator. He got progressively more bradycardia and hypotensive and the family decided against CPR. I was tied up doing a bedside procedure on another patient and so the attending physician was managing this particular patient. Eventually, the patient became asystolic so the attending physician pronounced him dead and the nurses disconnected him from the cardiac monitor and extubated him so the family could spend some time in the room before he was sent down to the morgue.

About 5 minutes after the family went in, they started shrieking and yelling that it was a miracle and he had arisen from the dead. One of his children had a camera and snapped a picture of the guy just as he sat up in bed with a shocked wide-eyed, open-mouthed expression on his face. The next week, that picture was on the front page of the National Enquirer with the headline “Patient Comes Back From The Dead”. The article included the name of the ICU attending physician who subsequently had to change his home phone to a new, unlisted number because of all the people calling him wanting him to bring back their own relatives from the dead.

What had happened was that the patient had breath-stacking due to the severity of his COPD and eventually breath-stacked enough that the high pressure inside of his chest prevented any blood return to the right ventricle and he became asystolic. Once he was taken off of the ventilator, the blood started to return into the chest and his heart started beating again. Although not well-recognized at the time, we now know this to be an important reversible cause of asystole during cardiopulmonary resuscitation and will usually give a trial of stopping ambu-bag ventilation in patients with asystole during CPR.

In this case, the patient did go on to die in the ICU a few days after his “miraculous” recovery from death. But ever since, I always wait a few minutes and re-check the pulse and respirations in a patient that I am pronouncing dead, even if I don’t have a sports page to read.

October 16, 2016


Inpatient Practice

Reducing COPD Readmissions

On average, about 1 out of 5 patients admitted to the hospital with COPD in the U.S. get readmitted within 30 days. There is a wealth of medical literature analyzing COPD readmissions. For example, we know that patients at risk for readmission include:

  1. Patients without physician follow-up within 30 days of discharge
  2. African Americans
  3. Older patients
  4. Divorced/widowed patients
  5. Those with longer initial hospital stays
  6. Patients in nursing homes
  7. Patients with anemia (hemoglobin < 8)
  8. Patients with renal failure
  9. Patients receiving cancer chemotherapy
  10. Patients with low health literacy
  11. Patients on Medicaid
  12. Patients taking > 5 different medications

There are a lot of reasons why they get readmitted. Some of the reasons include:

  1. Insufficient outpatient follow up
  2. Medication errors
  3. Poor transfer of information to primary care providers
  4. Inability to pay for medications
  5. Inadequate transportation
  6. Incorrect inhaler technique
  7. Lack of a “rapid action plan”

Interestingly, only 28% of patients with an initial hospitalization for COPD are readmitted with COPD. More than half of those readmitted are for non-respiratory conditions such as heart failure, arrhythmias, intestinal infection, sepsis, and electrolyte disturbances. Also, readmissions occur pretty quickly with 50% of readmissions occurring in the first 2 weeks after discharge. So what can we do to reduce COPD readmissions? Successful strategies employ interventions both during the hospitalization and after hospitalization.

During hospitalization:

  • Screen patients for readmission risk factors
  • Communicate with primary care providers
  • “Teach back” to educate patient (respiratory therapists can be valuable)
  • Use interdisciplinary clinical teams
  • Start on maintenance long-acting inhalers
  • Start on roflumilast (if indicated)
  • Discuss end-of-life wishes
  • Comprehensive discharge planning
  • Ensure patients can get and manage their medications
  • Schedule an outpatient follow up visit
  • Make sure patients have a nebulizer

After discharge:

  • Promote self-management (emergency action plans)
  • Follow-up phone calls
  • Develop and use transition clinics
  • Home visits for patients with transportation barriers
  • Electronic medical record management of information
  • Establish community networks
  • Use telemedicine when appropriate
  • Arrange spirometry testing
  • Enroll in pulmonary rehab
  • Smoking cessation

We started a nurse practitioner-run pulmonary transition clinic at our hospital and were able to reduce COPD readmissions to 12.5%. However, we did see a sizable no-show rate and those patients who failed to show had a very high (27%) readmission rate. The specific actions that occur in our transition clinic include:

  • Clinic appointment within 5 days of discharge
  • Assess response to treatment
  • Follow up lab and radiology tests
  • Arrange pulmonary function tests
  • Medication reconciliation
  • Refer to indigent patient medication assistance programs
  • Arrange pulmonary rehabilitation
  • Smoking cessation
  • Insure correct use of inhalers

Readmissions cost all of us in the long run since they increase insurance/Medicare/Medicaid costs. Care coordination and education are key elements of any readmission reduction strategy. Respiratory therapists are often in the best position to champion patient education in the hospital. Ultimately, it requires a culture change in our approach to COPD – culture always trumps hospital policy.

October 14, 2016

Inpatient Practice Outpatient Practice

You Can’t Get The Flu From A Flu Shot

vaccinationIt is flu shot season and my goal each year is to give more influenza vaccines in my clinic than any of the other pulmonologists. So, I offer it to all of my patients and continue to be amazed at how many of them decline because “Every time I get a flu shot, I end up getting the flu”. There is no live virus in a flu shot so you are just as likely to get the flu from a flu shot as you are likely to get pregnant by taking a birth control pill.

So why are patients so sure that they’ll get an infection from the flu shot. There are two main reasons. First, they may have had some muscle pain at the injection site or even some mild myalgia after a previous injection – this is a reaction to the vaccine and not an infection. If anything, it means that the vaccine is working because your immune system is mounting a response to it.

The other reason patients think that they get the flu from a flu shot is from superstition. The average American gets 2-4 upper respiratory infections (“colds”) per year. Lets just say it averages out to 3 colds per year. That works out to 1 cold every 17 weeks. In other words, statistically, 1 out of 17 patients will get a cold within a week of getting a flu shot purely by chance. Because they associate that cold with the flu shot, they incorrectly deduce that the vaccine caused the cold (which they equate to the flu). By the same argument, 1 out of 17 patients will get a cold within a week of Easter but you don’t hear patients telling you that they got the flu from the Easter bunny.

As it happens, if it wasn’t for influenza, I never would have been born. My grandmother’s first husband was one of the 21 million people who died of the “Spanish” influenza epidemic of 1918-1919. She then remarried to my grandfather so if her first husband hadn’t died of the flu, I wouldn’t be writing this post now. In the United States, about 23,000 people die of influenza each year; some years more and some years fewer, depending on the specific strains that go around that year.

It is particularly important for all healthcare workers to get vaccinated so that they don’t become a vector to transmit influenza to vulnerable patients. A few years ago, I admitted one of my patients with pulmonary fibrosis to the hospital with worsened shortness of breath. On admission, I did a bronchoscopy and sent PCR testing for influenza – it was negative. We determined that he was in heart failure and he improved over the days with diuresis. He lived alone and had no relatives so during his hospital stay, he had no visitors. After about a week, he became suddenly worse with hypoxemia and high fever. I repeated the bronchoscopy and this time, his influenza PCR was positive for influenza A. Based on the incubation period, he had to have acquired his influenza in the hospital. Since he didn’t have any visitors, he had to have acquired it from one of the doctors, nurses, or therapists. He never made it out of the hospital and died of his influenza in our ICU.

So, I’m pretty passionate about getting everyone who works in the hospital vaccinated for influenza each year. I don’t care so much whether they get influenza but I don’t want them transmitting it to a patient who would be more likely to die from it.

October 12, 2016