Categories
Outpatient Practice

The Obesification of America

prevalence-of-obesity-in-the-usAmericans are obese. We’re more obese than any other country and we’re getting more obese each year. The most recent results of the 2015 National Health Interview Survey were recent released and they paint a picture of the reality of Americans’ health. In 2015, 30.4% of American adults were obese. For those of you unfamiliar with the definitions, overweight is a body mass index (BMI) between 25-30. Obese is a BMI > 30. Obesity can be further stratified into different grades: a BMI 30-35 is grade 1 obesity; a BMI of 35-40 is grade 2 obesity; and a BMI > 40 is grade 3 obesity (also called morbidly obese). It used to be that morbid obesity sufficed as the term for people who were really, really obese. However, because so many people have moved into the morbid obesity range, a new class of obesity had to be added, the super obese, who have a BMI > 50. But if you drill down, there are some interesting findings. For example, Americans in the age range of yours truly, between 40-59 years old, are the most obese people in the U.S. Also, obesity is not a equal opportunity condition: African Americans are more obese than other racial groups.

age-and-race-and-obesitycountry-overweight-caloriesHow does the U.S. stack up compared to other countries? The best information comes from the “Organisation for Economic Cooperation and Development” or OECD. The OECD 2015 health data indicates that the United States is the most overweight of all countries on the planet. 70% of Americans have a BMI in either the overweight category or the obese category. I’ve just selected a few countries in this table but even when you look at all OECD countries, the United States has the highest percentage of its population being overweight. The other way of looking at this is that less than a third of Americans have a normal BMI. This is not something that we should be particularly proud of. One of the reasons that we are so overweight is that we take in too many calories. Here again, Americans lead the world. We consume an average of 3,750 calories per day. The only country whose citizens eat more than the United States is Austria at 3,800; however only 40% of Austrians report being either overweight or obese, presumably because they are more physically active than Americans. The recommended caloric intake for a middle-aged, moderately active adult is 2,000 per day for women and 2,600 per day for men (drop that number by 200 calories if that middle-aged person is sedentary). So we eat too much. Another way of looking at this is that Americans need to drop about 1,500 calories per day. Obesity is due to the confluence of two variables: calories in and calories out. If you want to become obese, you either have to have too many calories going in or you have to have too few calories being burned up. We are taking too many calories in, so what about calories being burned up?

 

physical-activityNot surprisingly, we don’t exercise enough. Although the percentage of Americans who do meet the 2008 Federal guidelines for aerobic and muscle-strengthening exercises during leisure time has been slowly increasing over the past 20 years, only 21% of Americans got enough exercise in 2015 according to the 2015 National Health Interview Survey. This is especially true for older Americans: the older we get, the less we exercise.

diabetes-in-the-usSome people argue that we have placed too much emphasis on obesity and physical exercise. I disagree. Obesity is at the root of so many medical problems that result in healthcare costs, disability, and death: sleep apnea, hypertension, hypercholesterolemia, arthritis, heart disease, stroke, breast cancer, colon cancer, and diabetes. In fact, the prevalence of diabetes over the past 20 years tracks almost perfectly with the prevalence of obesity. Along with diabetes comes foot ulcers, leg amputations, coronary disease, stroke, peripheral neuropathy, renal failure, retinopathy, not to mention the cost of medications like insulin.

 

If you add up all of the bad things that happen when you are obese, the result is that the higher the BMI, the more likely a person is to die. In a study from BMJ (the British Medical Journal) this year, researchers from the United Kingdom reviewed the world’s published literature on the relation of obesity and death and confirmed what has been generally accepted for many years. risk-of-death-by-bmiIf a person is excessively underweight or overweight, their risk of dying goes up. The graph to the right is for all persons but when the researchers broke down the results into smokers and non-smokers as well as persons followed for 5, 10, 15, 20, or 25 years, the curves look the same. The best BMI to have is 22-24. If your BMI is less than 22 (underweight), your risk of death starts to go up. Similarly, if your BMI is above 24 (overweight), your risk of death starts to go up. And if you are morbidly obese, then you are 3 times more likely to die in 25 years compared to a normal weight person.

So what can we as physicians do? First, we need to educate our patients about where their calories are coming from. That half-liter bottle of soda has about 200 calories. A Snickers bar, 215 calories. The large fries at your local fast food restaurant, 500 calories. And if you top those fries off with a medium milk shake, add 670 calories. Then if you finish off your day by splitting a medium pepperoni pizza with someone, that half of a 12-inch pizza cost you 900 calories. Total calorie cost = 2,485. If that same person instead had a diet soda, a couple of fun-sized Snickers bars, small fries, skipped the milk shake, and split a small pepperoni pizza, they would have cut 1,500 calories off of their day.

The other thing that we as physicians can do is to promote aerobic exercise in our patients. It doesn’t really matter whether that is running, swimming, treadmill, elliptical machine, or stationary bike. The best exercise is the one that the person will actually do. You can figure about 300-400 calories burned with 30 minutes doing any of these. Even regular walking for a half-hour burns up about 150 calories.

The irony is that obesity is what keeps me in business. Overweight and obese patient need to see the physician more often, they get sick and use our hospital more often and all of that translates into more medical bills that we get to submit to insurance companies and Medicare. But we as a society can no longer afford obesity. If we really want to keep health care costs down, the best way to do it is to keep our BMI down.

November 16, 2016

Categories
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

Categories
Outpatient Practice

340B Programs

pills-2Ohio State is about to expand its 340B program to include a free-standing pharmacy and the outpatient infusion centers. It gave me a chance to brush up on what a 340B program is. The 340B program was created by the federal government in 1992 as a way to provide discounted outpatient drug pricing to healthcare institutions that care for the poor. There are 6 categories of hospitals that are eligible that largely have in common that they are tax-payer funded to care for low-income and uninsured patients:

  1. Disproportionate share hospitals
  2. Children’s hospitals
  3. Cancer hospitals exempt from the prospective payment system
  4. Sole community hospitals
  5. Rural referral centers
  6. Critical access hospitals

In addition, hospitals have to either be state/government-owned, be a private not-for-profit hospital that has been granted governmental powers, or be contracted with the government to provide care to low income patients. In addition to hospitals, there are certain outpatient clinics that are also eligible to participate. As of 2014, there were 2,140 hospitals in the program, 90% of which are either critical access hospitals or disproportionate share hospitals.

The way the program works is that the Health Resources and Services Administration (HRSA) sets the maximum amount that drug companies can charge for outpatient medications – on average this is about a 22.5% discount. Medicare part B covers some outpatient medications (eg, cancer chemotherapy and rheumatoid arthritis infusion drugs); however, the hospitals participating in the 340B programs get paid the same from Medicare part B for these drugs as they would if they were not in a 340B program. Therefore, the hospital stands to make money on 430B drugs. On the other hand, drug manufacturers have to sell the hospitals their drugs at the discounted 340B price and so they would like to limit 340B programs so that they can have a higher profit.  All told, 340B programs save about $4 billion per year in drug costs. There are about 7,000 different drugs in the 340B program.

Ideally, hospitals participating the 340B programs use the increased margin that they get from the 340B programs to help support the care of lower income patients. For example, using profits to pay for rheumatoid arthritis infusion drugs for patients who are low income and have no health insurance and otherwise would not be able to buy these rather expensive medications. The danger is that there is the potential for some hospitals to expand chemotherapy and infusion clinics since they can make a higher margin on the chemotherapy and infusion drugs. Overall, 340B sales account for about 2% of total drug sales in the United States so it is not an enormous amount but 340B pricing is disproportionately affecting high cost chemotherapy and rheumatology biologic medications.

I can see both sides of the argument for the 340B programs but at least for our hospital, it will allow us to treat patients who previously were too poor to be treated for conditions like rheumatoid arthritis and inflammatory bowel disease in the past.

October 5, 2016

Categories
Outpatient Practice

“You Can’t Handle The Truth”: Immediate Test Result Release To Patients

In the movie, A Few Good Men, the climax occurs when a military attorney played by Tom Cruise questions a colonel played by Jack Nicholson during a trial about a murder on a military base and Nicholson famously says: “You can’t handle the truth”. We now have a lot of physicians saying the same thing about releasing lab test results to patients.

Electronic medical records have changed the way we practice medicine in many ways. As physicians, we are focused on how EMRs affect how we practice medicine. But there are also big changes in the way that patients receive medical care and this is often under-appreciated. In this case, it involves who really owns a patient’s medical record: the doctor or the patient?

There is a long history of doctors and hospitals being loath to share medical records with patients or other doctors. Part of it has to do with HIPAA laws and the fear that medical records will fall into the wrong hands. Part if it has to do with the time and expense that it would previously take to photocopy records. Part of it has to do with a suspicion that anyone asking for medical records is planning on using it to judge or sue the physician. But part of it comes from a fear that patients are going to pester us about every minor lab abnormality and create additional work for us explaining insignificant results.

Enter the electronic medical record. We can now organize and disseminate medical information better and more rapidly than ever before. One of the features of EMRs is the ability to communicate with patients, including electronically releasing their test results to them. When we first acquired our electronic medical record, we did not automatically release any test results and the physician had to decide for each test result whether he or she would release the result electronically to the patient. After a few years, we changed it to auto-release basic test results (like chemistry blood tests and CBCs) after 5 days, thus allowing the ordering physician 5 days to review and act on any results prior to the patient seeing them.

Last year, at our James Cancer Hospital, we made blood test results available to inpatients immediately through their electronic medical record. The patients really liked this a great deal and it improved satisfaction scores. Although there was some concern that hospitalists would be “scooped” by patients who often saw their blood test results before the patient, this really didn’t materialize.

This summer, we extended the auto-release to outpatients. It is only for fairly basic lab tests and not for sensitive results like surgical pathology results, radiology results, or genetic tests. Our hope is that we can improve patient satisfaction but the initiative was met by a lot of resistance by some physicians who were concerned about a barrage of phone calls from patients worried about insignificant test results.

Enter the monocyte count. When you order a complete blood count (CBC), you get 19 different results, most of which, you don’t really care about. One of the ones that most physicians care the least about is the monocyte count that rarely means anything significant if it is too high or too low. But if patients see that monocyte count as being abnormally elevated, they can panic because they don’t know if it is important or not. So the fear that was perpetuated by some of our physicians is that they were going to get inundated by panicky phone calls from patients worried about their abnormal monocyte counts.

My own opinion is that the medical records belong to the patient and not the doctor and patients have the right to see their blood test results. Personally, when I see my own doctor, I really like being able to immediately see what my routine cholesterol, hemoglobin A1C, or hemoglobin is when I’m in for my annual check-up. Most patients are a lot more sophisticated today than they were 20 years ago, before the advent of EMRs, and most patient are like me, they want and expect to see their lab results right away.

So far, I’ve only had one patient call about his high monocyte count after hundreds of immediately released lab tests. It is a pretty small price to pay for improved patient satisfaction. Personally, I think patients can handle the truth.

September 27, 2016