Antibiotics, Dentists, and You

Earlier this year the American Heart Association changed its guidelines on which patients would require antibiotics prior to a dental procedure. Last revised in 1997, these recommendations were established to provide guidance on what antibiotics to use and which patients were at risk to developing an infection of the heart valve which is known as endocarditis.

Endocarditis, fortunately, is a rare but serious infection. It occurs when bacteria enter the blood stream and deposit on to a heart valve causing damage. Bacteria enter the bloodstream via intravenous drug use but also can occur, but uncommonly, through medical procedures as well as dental procedures. Once present, bacteria can then to spread to different parts of the body causing further organ damage. If severe enough, surgery is required to replace the diseased valve. Treatment is usually intravenous antibiotics for many weeks.

The current recommendations for endocarditis prevention will mean fewer individuals will need antibiotics.

Individuals recommended to still take antibiotics prior to dental work include those with:

• A prosthetic heart valve.
• A history of previous endocarditis.
  
• A history of congenital heart disease (check with your doctor on the specifics).
• Individuals who received a heart transplantation with heart valvular disease.

If you previously took antibiotics routinely prior to any dental work, there is a good chance you won’t need to any more. Check with your dentist and doctor. Research has shown that it often take years for newly announced guidelines or beneficial research results to become commonplace and practiced routinely. You might have an opportunity to gently educate them. The Council on Scientific Affairs of the American Dental Association also endorsed the new guidelines so your dentists should be aware as well.

Routine Annual Physical - Not Worth the Time or Money

A recent article in the September 24th issue of Archives of Internal Medicine found that routine annual physicals may not be particularly useful. Although these types of visits account for 1 in 12 doctor office visits, the study found:

• only 19.9 percent of eight preventive services were provided at these examinations as opposed to other types of physician visits.
• only 8.8% of weight reduction counseling occurred during these visits.
• obtaining mammograms, checking for cholesterol, and recommending patients quit smoking occurred at more than half of these encounters.
• individuals in the Northeast 60 percent more likely to receive a routine physical than those in the West. (Note a recent study in Health Affairs also found that health care costs per capita were higher in the Northeast).

"We need to question encouraging everybody to come in for an annual physical," Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine and the RAND Corp., who led the study, said in a telephone interview.

"There's a lot of money, a lot of visits, a lot of adults going to see their doctor for annual physical exams with a real unclear benefit. It's the No. 1 reason adults see their doctor, and yet we don't know whether it's helpful or not," he added.

This is hardly a surprise. The value of having a routine physical is no more beneficial in finding problems than having your mechanic check your car, which runs completely fine, annually just in case. For decades, there has been no scientific evidence that an annual physical helps save lives. For those who are otherwise healthy, don't take prescription medications regularly for high blood pressure, diabetes, cholesterol, asthma, emphysema, or other potentially serious medical problems, there isn't much gained from a "check-up".

That should not, however, mean that individuals should avoid doctors either. Like you car which has a maintenance light which indicates servicing is required, patients must have tests that screen for various medical problems and cancers based on the age and gender of the patient. For example, all women without a family history of breast cancer should have a mammogram starting at age 40 and repeat every one to two years. While this screening could be done during an annual physical, the screening could be done at any other future visit. The study showed that many of these preventive interventions occurred at other office encounters.

Find out what tests you are due for at the U.S. Preventive Services Task Force. It is a good start, but not the final word. Check out other organizations like the American Cancer Society, the American Heart Association, and the American Diabetes Association as well.

If having an annual physical helps remind you that certain tests should be done to stay well then continue the practice. Otherwise, save your time and money. Figure out what tests you do need depending on your age and then get them done - no routine annual physical necessary.

Enough Flu Vaccination to Go Around - Just Do It

The Centers for Disease Control announced that for the 2007 - 2008 flu season, there are plenty of vaccinations to go around. According to CDC:

Every year, flu infects up to 20 percent of the population, causes the hospitalization of 200,000 people and kills 36,000.

People 65 and older are most likely to get vaccinated, 69 percent during the 2005-2006 flu season, the latest count available.

But that's still well under the national goal of vaccinating 90 percent of seniors — even though Medicare provides flu shots for free.

Just over a third of 50- to 64-year-olds are getting vaccinated, and just 30 percent of high-risk younger adults, CDC found.

The vaccine is recommended for anyone over 50 or under 5; people of any age who have asthma, heart disease, weakened immune systems or other chronic illnesses; and pregnant women.

From personal experience this past season, I diagnosed more confirmed flu cases that in the past. The impact of flu vaccination became clear when I examined one patient, in his late 30s who was vaccinated, feel well in a day or two despite having the flu and then saw others in their early 20s, who weren't vaccinated, feel miserable, bed bound, and wanting to die (they didn't of course). On follow-up, the latter group all without hesitation planned on getting the flu shot this fall.

Perhaps you should to, especially if you are a health care provider.

American Cancer Society Launches Healthcare Access Campaign

Perhaps a sign of how dire our healthcare system has become that the most prominent cancer awareness advocate, the American Cancer Society, now needs to involve itself with healthcare reform in order to be successful with its mission.

American Cancer Society officials launched what they described as an "unprecedented" campaign Monday to encourage a national debate about access to healthcare in the United States.

"We are here today to declare that lack of access to timely and adequate healthcare has become a major cancer killer in America," said John R. Seffrin, PhD, chief executive officer of the American Cancer Society. "Far too many Americans do not have access to cancer prevention, early detection, and treatment services that we know and have proven save lives."

Doctor, Retire the Prescription Pad and the Pen

A few months ago, a coalition of companies including Google, Cisco, Allscripts, Aetna, Wellpoint, among others formed an internet based electronic prescribing system. Known as ERx Now, it provides physicians, who register, the benefits of electronic prescribing for free. Benefits include a drug-to-drug interaction check, a check to see if you have an allergy to the prescribed medication, whether the medication is on your insurance formulary or if a generic equivalent is available.

Since the prescription is sent electronically to any pharmacy, you wouldn't have to drop off a prescription and wait for it to be filled or wonder when your doctor would call in the prescription. As long as he had internet access, a complete prescription could be written in the exam room. By the time you reached the pharmacy, it would be ready to go. No wait. No worries. Illegibility is not a problem.

It is a surprising fairly robust program given the fact that it is free. Physicians can access their patient's information, allergies, and medication information, past and present.

As someone who has been electronic prescribing for a couple of years, the ability to provide even safer care with automatic drug interaction and allergy checking, the ease of refilling prescriptions at a click of a button, and the option of accessing critical patient information anywhere there is an internet connection, allows me to deliver better care.

In the past, physicians could argue that installing systems that allowed electronic prescribing, among other features, was simply too expensive. Now, with this free internet program, there is NO excuse not to adopt this practice. The only reason your doctor could justify not getting rid of his prescription pad is if he (a) never heard about this program or (b) doesn't have a computer and/or internet connection. Even then, does that trump your safety?

Open Enrollment - Picking Health Insurance As If Your Life Depended On It

It's that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the "perfect" Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention.

But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimated that in 2005, 83, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely -- because the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association were not done.

The performance gap between the top 10 percent of health plans with the national average on measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, exceeded 20 percent. For the airline industry, banking, and manufacturing, the quality gap was less than 1 percent. Would you be worried about flying if you knew the safety performance between the best and average was 20 percent. When it comes to health care, consumers erroneously assume that all health plans are created equal.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . Only this recently have PPOs (preferred provider organizations) started to submit their performance on these basic, yet important preventive measures. It is possible that you still have a chance of not knowing whether you're choosing a poor-quality health plan this year.

What can you do? You aren't completely powerless. First, check out the NCQA website and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It's your money. Don't you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. With hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.

Concierge Medicine - Not Worth the Money

Recently the article First-Class Health Care -- For a Price caught my attention. It talked about the practice of boutique or concierge medicine, that is hiring a doctor on an annual retainer which would be in addition to health care insurance premiums as a way of providing better care. One of the converts was quoted as "Fifty to 75 percent of known preventive measures don't get done. This boils down to one thing -- time."

What the article failed to mention is that throughout this country there are already healthcare organizations and medical providers that do consistently get the preventive measures done at very high levels. The National Committee for Quality Assurance, which evaluates health insurance plans, estimated that in 2005, as many as 83,000 Americans died prematurely not because of hospital errors, misdiagnoses, or negligence, but because they did not get care in accordance with guidelines from national expert committees, and they did not get the care backed by scientific evidence and research. In high quality health plans, simple factors like controlling high blood pressure, lowering cholesterol, and managing diabetes to the recommended levels get done and needless hospitalizations and deaths are averted.

Our healthcare crisis is not helped with concierge medicine practices. These are far from being a patch for an ailing system. There is NO evidence that the care provided by concierge medicine physicians is better than existing care. One could argue that will a much smaller number of patients and decreased breadth of practice the clinical skills of these doctors could deteriorate.

There is evidence, however, that within our country there are amazing healthcare organizations and medical providers delivering first-class healthcare consistently that does not require an annual retainer. More and more medical providers are offering same day appointments, not forced or double booked appointments, as well as the ability to email them, retrieve lab results, order medication refills, and book appointments on-line.

The real trick is Americans must reward these organizations and medical groups by seeking and demanding to have these options available to them. By patronizing these exceptional performers the same way we use other consumer goods and services will real change and better healthcare occur in this country.

NY Times Letter - Sending Back the Doctor's Bill

My letter to the New York Times editor.

Dear NY Times:

I was very troubled by the suggestion that physicians "give up some of their autonomy" by moving to a salaried system or that as a whole are overpaid in "Sending Back the Doctor's Bill" (NYT July 29th). The problem is that the current method of payment is flawed. Let me be clear, I don't blame physicians for the way they deliver care. If I was compensated the same way most physicians are, I would expect much of my autonomy to be given up and my clinical judgment clouded as I worried about which tests, diagnoses, and procedures, I needed to do to stay financially solvent rather than what the patient needed done to stay well.

This has already occurred. Our nation is the worst compared to other industrialized nations on three aspects of health care. We have the highest health care cost per capita, we have the worst in health care outcomes, and we have millions uninsured.

Instead of re-inventing the wheel our leaders should look to already successful and proven health care delivery systems and programs which exist in our country and adopt their methods.

Fortune - Andy Grove's Answer to Fixing the Healthcare Crisis

My letter to Fortune magazine responding to Andy Grove, the former CEO of Intel, and his thoughts on how to fix America's health care crisis.

Dear FORTUNE:

As a practicing family physician, I found that what Mr. Grove's and many health care reform proposals fail to address is the shrinking supply of primary care physicians. Annually fewer U.S. medical school graduates choose to practice either family or internal medicine, yet demand for these providers increases as Americans live longer with more complex and chronic medical conditions. Countries with a robust primary care workforce not only improve the overall health of the population but also do so at a much lower cost by coordinating care, minimizing duplication of services, and intervening to prevent illness. Without addressing this problem, the prognosis is clear and grim. More Americans will suffer from expensive medical complications that were unaddressed and avoidable. I am thankful that I have the knowledge and expertise on how to stay healthy. The question is will you?

Banning Pharmaceutical Representatives

It was encouraging to learn that the Hospital at the University of Pennsylvania (HUP), started prohibiting its physicians from accepting gifts from pharmaceutical companies. HUP
joined a growing list of academic programs like Yale and Stanford as well as the integrated healthcare organization Kaiser Permanente in establishing such a policy. With these types of programs in place, patients can feel much more confident that the medications their doctors prescribed are the most appropriate for their needs.

Healthcare Reform Needs IT support

In 2006, the New England Journal of Medicine published a study that found regardless of an individual's socioeconomic, demographics, and health care insurance status that uniformly Americans only received the recommended medical care just a little more than half the time. Slightly better than a coin flip. Perhaps more concerning is what was not said, - our nation does not have the desire or the plan to overhaul and implement the "large-scale, system-wide changes" to our dysfunctional health care system needed to provide quality health care to all.

Two-thirds of Americans currently rate the health care system as fair or poor. Fewer employers are offering health care insurance to their workers and retirees due to unstoppable increases in premiums. Instead of improving the system, the federal government and health care insurers major focus is the active promotion of health savings accounts and consumer driven health plans with high deductibles. By not insulating patients from the actual costs of care, it is hoped that market forces will slow costs and improve quality as patients also become consumers.

But gains in health care quality will not be driven by an informed public. Unlike other goods and services consumers compare routinely, evaluating medical care is not easy. In a system requiring more patient responsibility, a survey found two-thirds of Americans would still simply follow the advice of their physicians rather than researching the options. Yet the vast majority of patients get their care by physicians who need to rely on and sort through paper charts trying desperately to find the information they need to give the right intervention and do so only 55% of the time. Annually it is estimated that 83,000 Americans died simply because they did not receive the recommended care.

The good news is that there already are a few health care organizations and medical groups that consistently provide their patients the recommended care. Organizations like the National Committee of Quality Assurance and the Leapfrog Group continue to identify providers, health plans, and hospitals that perform at this high level. Unfortunately these groups are more the exception than the rule.

One of these high performers is the Veterans Administration. In a study published two years ago, the VA performed as well and at times better than the best commercial health plans in diabetes care. This was not always the case. The VA's recent success was due a leadership change that focused relentlessly on delivering quality care and provided its physicians the information technology infrastructure and tools to not only collect, evaluate, and improve their patient care, but to do that repeatedly and routinely across all VA medical centers.

It is clear then that the path to improve health care quality is not shifting more costs to the patients, nor is it going to be solved by requiring employers and the government to spend more money on a health care system that cannot deliver on its potential.

Unless the public and our leaders demand a complete system overhaul, the rapid implementation information technology support systems to help all providers focus on health care quality, our current and future generations cannot and should not expect to live healthier and longer than their predecessors. This is not a prediction. As it stands, this is our legacy to our children. This is their destiny.