Monday, May 24, 2010

Brittany Murphy's Death - Learnings About Consumer Driven Healthcare and Pneumonia

Actress Brittany Murphy, age 32, died unexpectedly in December 2009 as a result of pneumonia. An autopsy report noted elevated levels of medications, like Vicoprofen, which contains the narcotic hydrocodone and other medications, the anti-histamine chlorpheniramine and L-methamphetamine which is found in decongestants. The hydrocodone in Vicoprofen can cause sedation and was used by the actress to treat menstrual cramps. The other medications are often used for symptom relief from respiratory infections.

Her husband noted that Murphy "was on an antibiotic and was taking cough medicine." Yet it is unclear if she was actually under the care of a doctor at the time of death. Other reports noted that the "star had been feeling ill prior to her death and had scheduled a doctor’s appointment on a Wednesday or Thursday — days before her Sunday death."

Her husband had been ill a week before and recovered so it was certainly reasonable for the actress to care for herself at home.

So what can we learn from this tragic and untimely death?

First, even in the 21st century pneumonia can kill despite our advanced antibiotics and medical technology. Among adults in 2000, there were about 135,000 hospitalizations due to pneumonia, and 60,000 cases of invasive disease, which included 3,300 cases of meningitis. Of those patients with the aggressive invasive disease, 14 percent were fatal.

Bacteria is becoming more resistant to medications as antibiotics are overused in treating viral infections, like colds and sinusitis, as well overuse in food production and livestock.

Patients at risk of pneumonia, elderly, young children, those with compromised respiratory systems (emphysema, asthma) and immune systems (diabetes) should ask their doctors about the pneumonia vaccine. Prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

The type of vaccine administered varies depending on the age of the patient. For children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

It's unlikely Murphy would have needed a pneumococcal vaccine based on her medical history, which was otherwise healthy except for anemia, which is not unusual among women who are menstruating. However, according to the autopsy report the coroner noted a history of diabetes which alone would have been a reason for vaccination.

Second, it is unclear what dosages Murphy was taking of each of the listed medications. Certainly taking too much of any medication can be problematic particularly with hydrocodone and the chlorpheniramine. Both can cause sedation. The former drug can cause respiratory depression and decrease the drive the breathe, which can be fatal when taken in high doses.

Again it is unclear if she was under the care of a doctor at the time of her illness. Her husband notes that she was taking an antibiotic for a flu like illness. Yet, antibiotics are not appropriate for viral illnesses like the flu. Based on information from the coroner's report, the antibiotic clarithromycin which is used for pneumonia, was prescribed to her on November 17th, 2009, a month before the actress died. Was she ill before her December illness?

Finally, the assistant chief coroner noted that her death was "preventable".

Could Murphy have known how sick she was and how urgently she needed to seek medical care? It would been perfectly natural for her to have assumed that since her husband was recently ill and subsequently recovered that she would have done so as well. Isn't that what many of us do?

With increasing healthcare costs, many healthcare advisors are touting consumer driven healthcare as a way to slow medical expenditures. The theory goes that by having patients shoulder more financial responsibility on when to seek medical care and when they can safely skip advocates believe as a result people will make smarter choices and lower healthcare costs.

This is quite concerning.

Murphy, who arguably didn't have a financial barrier to seek care yet was quite ill, didn't get timely medical care. One wonders if individuals facing $50 to $100 office visits who might be equally as sick would simply stay home as well. At best, they might delay care and then subsequently end up in the emergency room or hospital not only requiring a lot more care but also a significant amount of out of pocket costs in the hundreds to thousands of dollars. At worst, they could die and have a death that was preventable.

Consumer driven healthcare, which is coming soon to you, requires that patients educate themselves in a way unprecedented than the past. Perhaps if Murphy had reviewed the symptom checker at the American Academy of Family Physicians she would have demanded an earlier appointment. (According to the coroner's report, Murphy was complaining of shortness of breath).

Instead of winging it, patients in these health insurance plans must educate themselves otherwise they are truly taking their lives into their own hands.

And the ignorance could be deadly.

(Sadly, her husband, Simon Monjack, age 39 was found dead today at home. Preliminary reports indicate he died of natural causes. Certainly he could have died from a broken heart).

Wednesday, May 19, 2010

Our Big Problem - Obesity - Who Will Solve?

The Wall Street Journal recently published Our Big Problem: Obesity penned by a British physician Anthony Daniels, pen name Theodore Dalrymple, who feels that the weight problem is due to fragmentation of families when it comes to meal times. Families don't prepare or enjoy meals together. Fast and already prepared foods dominate the kitchen table. It is simply a consequence of the modern society we live in. He wishes that the fast-paced fragmented American family life will return to the days of home cooked meals and sit down dinners.

He recognizes that this ideal world is highly unlikely. As a result, he suggests that is that government should regulate and restrict further the food we eat. Sugar and fat content of fast foods would be an area of government intervention.

He'd better be kidding. Anyone who has been watching Jamie Oliver's show Food Revolution has seen how well intentioned government regulations on school nutrition can result in very unhealthy food that fulfills the requirements but not healthful. (Is a squirt of ketchup really a vegetable serving?). Government does have a role in society, but will be unable to fix this problem.

Unfortunately doctors can't stop the obesity epidemic either. Recent reports noted that primary care doctors lack the training and resources to address the issue with their patients, even as they feel the responsibility to provide advice. The problem is that in a survey of 290 doctors found that 72 percent had no one in the office trained to discuss weight management. Of the 90 percent of obese patients who were counseled to lose weight about a third of patients noted they weren't told how to lose weight.

Winning the war on obesity won't come from government regulation or somehow getting doctors to be better in educating and counseling patients. It won't be families resorting to a simpler slower pace of life that existed a couple generations ago.

Winning the war on obesity and turning the tide will be due to the same large multi-national organizations that are being vilified. McDonald's top chef, Dan Coudreaut, will impact more lives on a daily basis than any doctor could ever advise over an entire career based on his latest creation which graces the McDonald's menus nationally. The real question is whether our corporations will begin taking on this new social responsibility in keeping our nation healthy or would they rather wish to continue to kill their customers slowly from inside out and dump the health consequences onto an increasingly dysfunctional expensive healthcare system, other employers via escalating premiums, and ultimately destroy US competitveness by creating an unhealthy fatter workforce that is unable to meet the challenges of the future?

Although there will be people quite skeptical about businesses and corporations fixing the problem which they helped create, it appears that this is the case. The Washington Post noted that large food organizations are committed to reduce the calories in existing products, offer healthier selections and smaller portions.

The Healthy Weight Commitment Foundation, a coalition including Campbell Soup, Coca-Cola, General Mills, Kellogg, Kraft Foods and PepsiCo, will slash 1 trillion calories by the end of 2012 and 1.5 trillion calories by the end of 2015. The 16 members make 20-25 percent of food consumed in the United States. The Healthy Weight Commitment Foundation, a coalition including Campbell Soup, Coca-Cola, General Mills, Kellogg, Kraft Foods and PepsiCo, will slash 1 trillion calories by the end of 2012 and 1.5 trillion calories by the end of 2015. The 16 members make 20-25 percent of food consumed in the United States.
This is an encouraging first step. Maintaining a healthy weight is more than asking individuals to choose wisely every meal. It's about helping the public makes the right desired choices by creating products that are healthy, nutritious, and lower in calories. Restaurants and food organizations must lead the way to slow and then reverse the trend.

Otherwise with the status quo, children born since 2000 will the first generation of Americans not to live as long as their parents due to obesity related illnesses like diabetes.

Secret to weight loss is simply: Eat less. Move more. When companies get it right, eating less will be easier to do.

It will be the private sector that begins to solve the obesity problem.

Thursday, May 13, 2010

Life Line Screening - Worth the Money?

A patient brought in a flyer for Life Line Screening where for $129 an individual can have their carotid (neck) and peripheral (leg) arteries screened for blockage, abdominal aorta for aneurysm (swelling), and osteoporosis. The advertisement claims that "we can help you avoid a stroke" and their logo notes Life Line Screening - The Power of Prevention.

The question is whether having this Life Line Screening test is worth your money?

Short answer? No.

Although the flyer correctly indicates that 80 percent of stokes can be prevented, the National Stroke Assocation does not recommend ultrasound as a screening test. Preventing stroke includes quitting smoking, knowing your blood pressure and cholesterol numbers, drinking alcohol in moderation (if already doing so), regularly exercising, and ingesting a low sodium diet. Their is no mention of an ultrasound test. Why?

Because there is NO evidence that this type of ultrasound testing saves lives in individuals who are healthy and have no symptoms except for the following situations.

The United States Preventive Services Task Force (USPSTF) latest guidelines recommend only screening men between age 65 to 75 years old who have ever smoked to be screened for an aortic aneurysm. If you are in this group, ask your doctor for an ultrasound.

For women, osteoporosis screening should begin at age 65 years old and have a bone density test done. Among the "different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture." It is unclear how accurate or how good ultrasound of the heel or wrist is compared to the bone density test. If you feel you have other risk factors, like family history, use of steroids for a long period of time, then check with your doctor to see if screening should be done sooner. Otherwise at age 65, all women should be evaluated not with an ultrasound but a bone density test.

USPSTF recommends against screening for peripheral artery / vascular disease (PAD) as well as carotid ultrasound.

Worried about either condition? Ask your doctor. For peripheral vascular disease, particularly when significant, individuals commonly have leg pain when walking. The blockage in the arteries decreases blood flow to the leg muscles when active causing pain. When the person stops walking, the pain resolves. A doctor can determine whether you have PAD by seeing if you have good foot pulses simply by placing fingers on the pedal pulses. If your pulses are normal, then you don't have significant PAD. If the doctor is concerned about your symptoms, he will order an ultrasound which will be covered by insurance.

There is a reason why Life Line Screening in small print writes that they do "not participate in the Medicare program and the cost of [their] screening services is not covered or reimbursable by Medicare" as well as they do "not file insurance claims and the cost of [their] screening services is your responsibility."

There is NO scientific evidence these tests can make a difference except in the specific situations listed above. Since insurance companies and Medicare only want to cover what is proven, Life Line Screening wants you to pay for an essentially unnecessary test.

Better use for your money? Check your blood pressure and your cholesterol. Quit smoking. Cut down alcohol use if you already drink. Maintain a low sodium diet. To prevent osteoporosis, women should take 1200 to 1500 mg of calcium per day as well as 800 to 1000 IU of vitamin D daily.

For $129? Get a really nice pair of walking shoes. Get a pedal exerciser for under your desk. Keep your muscles moving and maintain a healthy weight.

Oh, please don't spend too much money on multivitamins because they aren't worth the money either.

Want more helpful tips? Worry about whether you are getting the best medical care? Does your doctor seemed rushed? Not answering your questions? I have a solution for you!

Tuesday, May 11, 2010

Tiger Woods and Neck Injury

Tiger Woods recently withdrew from The Players Championship golf tournament due neck pain and spasm as well as shooting pain starting from the neck to the right hand. According to the Associated Press, Woods started noticing neck pain about two weeks before the Masters, which was about five weeks ago.

What does he have? Is his care appropriate? What will the MRI show? What will his treatment plan be?

Neck pain with symptoms of numbness or tingling to a hand is common problem I see in the office. Typically it is due to a pinch nerve of the neck which can be due to a herniated disc or arthritis. Symptoms of the numbness, tingling, and burning pain radiating from the neck to the shoulder or hand can last six to eight weeks. Patients may or may not have neck pain depending on the location of the nerve irritation.

Assuming no hand or arm weakness due to the pain, it is reasonable to wait six to eight weeks before getting a MRI. The vast majority of cases resolve by that time. If symptoms still persist or worsen, then a MRI can be done sooner. Although Woods has not indicated which right fingers are most affected from the pain, doctors can determine which nerve is most likely involved by referring to the dermatomal distribution or nerve map of the body.

If the pain is mainly from the neck radiating to the thumb, then the nerve pinched is the right C6 nerve. Index and middle finger involvement would be the right C7 nerve. The little finger discomfort would suggest the C8 nerve. If Woods reports that his entire hand feels asleep, it is possible there is are multiple discs pinched or that the area of irritation is large enough to affect more than one nerve.

How the neck is positioned relative to the spine can also impact the degree of pain. Certainly with the neck bent forward to extended backwards can cause the more nerve irritation by closing the spaces of the spine where the nerves come out. While normally not a problem, any degree of swelling or inflammation can make a normally good fit now too small for the nerve. Because golf not only requires the neck to be flexed to address the ball as well as force to drive, it isn't surprising that Woods often was seen standing up, rubbing his neck, flexing his fingers, and having some physical therapy treatments all to try and decrease his symptoms.

Treatment can include anti-inflammatories, like ibuprofen or naprosyn, steroids, narcotics for pain, as well as medications that decrease the nerve pain. To decrease the amount of pressure to the nerve, neck traction, which can be taught to patients by physical therapists, or acupuncture may be helpful. From news reports, it appears Woods has only done anti-inflammatories and physical therapy.

In my experience, rarely do individuals need neurosurgery to treat the symptoms.

Up to date, his care seems appropriate. It is unclear when the arm pain started. As noted previously that symptom can take six to eight weeks to resolve.

Woods is incorrect in the sense his future depends on the MRI. What the MRI will tell us is whether a herniated disc is the culprit or not. Without the MRI, doctors can predict with a high degree of certainty that the areas of concern are nerves C6 to C8. If there is a herniated disc, the real questions Woods should ask are the following:

  • Will the symptoms come back?
  • Can golfing make the problem worse or will it merely flare-up symptoms?
  • Are there exercises or non-surgical treatments that can decrease likelihood of recurrence?
  • Is surgery necessary? If so, will it prevent symptoms from coming back or are the chances of recurrence the same without surgery?

If the MRI shows no herniated disc, it is possible the nerve irritation could be outside of the neck, though those are uncommon causes. Based on his description of symptoms, it is highly unlikely to be due to a shoulder or rotator cuff problem. Even less likely would be a mass or growth around the nerve.

It does not appear that his current symptoms are related to his car crash in November 2009, which apparently was low speed. The neck injury Woods suffered at that time sounded more muscle related. Those injuries tend to resolve in two to three weeks.

Prediction? MRI will show a herniated disc. If his symptoms continue to persist, then he will likely consider surgery. The question really will be whether surgery can cure his problem. If not, then he will simply need to deal with it the same way many individuals do for neck radiculopathy, pinched nerve of the neck.

There is a very good chance, however, given his ability to exercise and his legendary regimens for physical conditioning that he won't need any surgery. Time will tell.

Wednesday, May 5, 2010

The Decision Tree: How Smarter Choices Lead to Better Health - Really?

An article in Wired magazine called the "The Decision Tree" really got me thinking. In the book excerpt, the writer suggests that patients can get to the best decision using a simple tool, a flow chart. Making a good choice relies on the following:
  • inputs - data that might affect our health
  • process - an action we can take to change our outcome
  • decision - a question that nudges us to make deliberate choices and
  • end result - the consequence of the decision process
Certainly with the explosion of medical information and the ability to access that information quickly and easily because of the internet, anyone can read up and educate himself on the latest scientific research. A simple flowchart is a reasonable structure to organize a plethora of information so that it is usable and actionable.

What troubled me, however, was the implicit message that simply taking tests, like genetic testing for a fee, or getting a wealth of medical data and then using a decision tree could result in patients choosing the right care for themselves. The internet has allowed individuals to no longer rely on experts to book plane tickets or manage our investments. The author seems to suggest that in healthcare we've reached the time that patients can empower themselves in a similar manner.
[We’re at a moment] when more data than ever lies within ready reach. Whether it’s personal genomics services like 23andMe or screening tests or self-tracking iPhone apps, each of us can draw on a wealth of personalized data sources that turn generic medical advice into customized health equations. And this is always-on data: Instead of checking in on our health episodically — when we visit the doctor or get lab test results — we can now tap into a constant stream of information and opportunity. We can minimize our uncertainty and maximize our control. We can build ever more sophisticated, and useful, decision trees.

If it was really that simple. There are significant nuances between the theoretical and practical, especially when it comes to genetic testing, which in many instances has not yet been proven to be an accurate predictor about one's future health. To understand the nuances take the simple routine cholesterol test. You already know to eat healthy, exercise, and maintain a healthy weight to achieve a lower cholesterol. Your question is whether your total cholesterol of 280 and a HDL (good cholesterol) of 35 is a problem? Do you need to take a cholesterol lowering medication?

The answer depends.

If the patient is a 40 year old man, who smokes, and otherwise healthy with a blood pressure of 120, then his risk of a heart attack is 21 percent over the next decade.

If the patient is the same man, but a non-smoker, his risk now is 5 percent over the same time of ten years.

If he is a non-smoker, but taking medication to maintain his blood pressure at 120, his risk for heart attack becomes slightly higher at 6 percent.

For the first example, the first thing the person should do is to quit smoking. The risk of heart attack drops by 75 percent. If he refuses, then his doctor should recommend starting a cholesterol lowering medication as well as suggesting taking an aspirin daily. In the last two examples, the risk is small enough that diet and exercise alone are adequate. Would a flowsheet have captured this difference in outcome?

While a decision tree and flowchart can be helpful and it is likely doctors are using a similar algorithm in our heads, the issue is who is interpreting the information. A flowchart for a critical health care decision may get the patient an end result. In situations where newer tests and technologies are involved, a review with a doctor who has the experience and expertise, will provide the framework for a candid discussion and a great result.

If this article demonstrated anything then it is that we as doctors have consistently failed to take the medical information available, interpret, translate, and then communicate clearly the risks, benefits, and choices personalized for an individual person. We can and must do better.


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