Category Archives: Clinician-Patient Relationships

Information Can Change Medical Practice, Patient Behaviors, and Kill Kids

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Medical information can change how clinicians treat patients, how patients care for themselves, and how healthcare payers promote or prevent the use of treatments and diagnostic tests. However, this information can act as either a broad sword or a scalpel, and produce good or bad outcomes.

A recent report from a Canadian new service about an article from the Canadian Medical Association Journal describing the outcomes from warning about the use of anti-depressants in children brings this issue down from a general concept to being very specific. This news report stated:

Two years after Health Canada warned about prescribing anti-depressants to children, the number of children and teens who died by suicide increased 25 per cent after years of steady decline, major new Canadian research shows.

And the increased suicide rate coincided with a 10-per-cent decrease in the rate of visits to doctors for the treatment of depression in children.

For the study, researchers tracked what happened in Manitoba before and after Health Canada warned in 2004 that newer antidepressants may be associated with an increased risk of “suicide-related” events in patients under 18.

They found the warning was followed by an overall 14-per-cent drop in antidepressant use among children and adolescents, fewer visits to doctors for depression, and – among eight- to 17-year-olds – increased rates of completed suicide.

More than 90 per cent of the children and teens who killed themselves were not taking antidepressants when they died.

Published Tuesday in the journal of the Canadian Medical Association Journal, the study is the first to document “such a wide range of unintended health consequences” from a major drug warning, the authors say.

Lead author Dr. Laurence Katz, a child and adolescent psychiatrist in Winnipeg, warns the increased risk of suicide could be a “random fluctuation.”

“We can’t say the warning, or the change in antidepressant use or the physician office visits caused changes in suicide rates,” says Katz.

The suicide rate among children and teens was also still relatively small, from 0.04 for every 1,000 children and adolescents before the warning, to 0.15 per 1,000 after.

But Katz worries the widely publicized drug warnings have led to more cases of untreated depression, and an impact “beyond what was intended.” The drop in doctors visits for depression suggests that some vulnerable children are getting no treatment, including psychotherapy, at all. He says his hunch is that families were afraid to go to the doctor for fear their child would be put on medication.

“But that’s not the only treatment for depression. Not going to the doctor deprives you of all forms of treatment.”

If anything, researchers expected office visits to go up after the warning was issued because physicians were urged to increase the monitoring of patients for potential adverse reactions.

Katz, an associate professor of psychiatry at the University of Manitoba, says the drug warnings and media response may have “generated a lot of fear.”

“Understandably parents who kept bringing their children, their teenagers in for troubles with depression were already struggling, and fearful (and) often appropriately cautious about whether their child or teenager should be put on a medication.”

Katz believes the findings could be applied to any Canadian jurisdiction. Other studies coming out of the U.S. are showing similar results. [Emphasis added]

The antidepressant warning involved drugs known as SSRIs, or selective serotonin re-uptake inhibitors, a class that includes Prozac, Paxil and Zoloft, as well as serotonin noradrenaline re-uptake inhibitors (SNRIs), which include Effexor. The drugs have not been approved in Canada for children, but doctors have prescribed them “off-label,” which they are legally permitted to do, to tens of thousands of toddlers, children and teens for depression, social phobia, anxiety and obsessive-compulsive disorders.

In 2003 the U.K. banned antidepressants for children. The only exception was Prozac. Studies have shown the drug is safe and effective in children.

A year later, Health Canada warned that people taking the newer-generation antidepressants may experience behaviour or emotional changes that may put them “at increased risk of self-harm or harm to others.”

Katz says he didn’t have a problem with the warnings themselves. But he says some people leaped to the assumption “that these medications lead people to kill themselves.”

[The report also notes that, “For young adults, there was no significant change in the rate of completed suicide.”]

Obviously, the outcomes found in this study are very worrisome, but it also a too dramatic example of the principle of unintended consequences.

It also reminds me of how a news story in the early 1990s about adverse reactions with the second medicine to treat AIDS.  This news report caused many AIDS patients to stop taking the medicine, and given that there was only one other medicine to treat AIDS, this certainly wasn’t a good thing for their long-term survival

Although correlations don’t prove causations, I think this study definitely underscores the importance of healthcare regulators – and their media colleagues – carefully considering how they present new health information and notices to the public – for both good findings or dire warnings. With all the proposals to empower patients to make their own decisions through consumer directed insurance plan, and to give people more health information, there should also be much more research into how people respond to health related information delivered in different forms from various sources.

Ensuring Enough Primary Care Clinicians

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Like many complicated problems in the US healthcare system, setting a goal can be easy, but achieving it can be hard. In recent years there has been a number of proposals for increasing the use of primary care clinicians to help patients with chronic diseases (like diabetes) manage their care and avoid long-term complications – and to presumably lower long-term healthcare spending. For example, the “Patient Centered Medical Home” proposal supported by a dozen organizations, (including companies and family practice and pediatrics associations), doesn’t specifically use the term “primary care,” but it gets to the same result – heightened relationships and communications between patients and a particular clinician or clinic. This .

Increasing the use of primary care clinicians is a great concept, but as has been seen in Massachusetts, increasing relationships between primary care clinicians and patients often runs into a wall when you improve insurance coverage. A recent New York Times article reported on what people here in Massachusetts have been talking about for some time: Before the start of the Massachusetts insurance expansion program there were parts of the state where it was hard to find primary care doctors taking new patients. Now that the program has expanded insurance coverage to about 340,000 more people, it has gotten really hard – particularly in Western Massachusetts. (A friend of mine moved to the most Western part of the state last summer, and almost had to go 90 minutes to Hartford, CT to find a primary care doctor.)

The options for increasing the number of primary care clinicians have both logistical and cultural challenges: Training more physicians takes many years, and as the Wall Street Journal on-line reported, until a few years ago, it had been 30 years since a new medical school granting the MD degree had opened in the US. (Several new osteopathic medical schools have opened.) Another option is retraining specialized physicians to practice primary care. This not only takes time for the retraining, but almost invariably, the potential income from practicing primary care will be less than practicing in a specialty area – which is why physicians aren’t lining up to go back into primary care.

The cultural barriers to increasing the supply of primary care clinicians involve biases that vary in different parts of the country towards osteopathic physicians (ODs DOs) and foreign born physicians, as well as against physician assistants (PAs), and nurse practitioners (NPs). Too many patients – and particularly around places like Boston – want to see an MD that trained at an Ivy league medical school and hospital. (Having graduated from an Ivy league medical school, I can tell you that’s a credential which alone is certainly not a perfect measure of a clinician’s quality.)

Another interesting proposal has been raised in the United Kingdom, where according to the Financial Times, the UK’s National Health Services wants to start having pharmacists provide some primary care services – “pharmacists prescribing drugs and administering tests for minor ailments will free up time for family doctors.”

Of course what this all comes down to is money. The UK pharmacists welcome the proposal, as long as it is backed up with funding to pay them for their increased work. And with the battle over Medicare payments to physicians looming with the 0.5% increase in the Sustainable Growth Rate set to expire at the end of June, (and then revert to the default formula’s 10.1% reduction), it would be nice if Congress (or Medicare itself) could weigh into this policy problem and adjust how they pay clinicians to increase incentives for primary care services. However, my understanding is that Medicare still pays according to the type of service (e.g. intermediate office visit), without regard to the type of physician (e.g. primary care or specialist).

So my conclusion is that while money seems to be a driving force behind the primary care clinician shortage, there needs to be some more good thinking about how to redirect money to increase the supply and availability of primary care, as well as how to use other forms of influence to address some of the cultural and logistics problems keeping the functional supply of primary care clinicians smaller than it could be.

Any ideas? Criticisms? Rants? Raves?

E-Health – A Medical Information Miracle or Mess?

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Information technology tools has been touted for years as a cornerstone for improving the quality of healthcare and reduce spending. While, clearly this has not been achieved, many e-health initiatives are being launched, and it is unclear how successful or efficient these will be. I am often concerned about the effect e-health systems have on the health care quality when my own physician spends so much time looking into and typing on his laptop. But to avoid discussing the challenges of e-health based upon my n of 1, below are 4 perspectives that are more expansive and analytical:

The Commonwealth Fund recently released a report about 27 state governments’ e-health activities in 2007. One remarkable thing about this report is that while there was consensus “that health information technology (HIT) can significantly improve health care delivery and quality and reduce its costs,” states are pursuing a broad range of HIT initiatives:

State E-Health Plans

While Health Information Exchanges (HIEs – which enable the sharing of medical information among clinicians in an area/region), are the highest priority for most states, after that, the consensus starts to break down.

What worries me, is not the lack of activity, but the lack of consistency in implementing any of these systems. I don’t think it would be wise for everyplace to use the same medical records system, etc., but too often the “lets put in an e-health system” decision is supported with a lot of money but without enough up-front time and planning to make the new system actually provide value to patients, clinicians or the overall health system.

The Commonwealth report also has information about the barriers to accomplishing e-health priorities:

  • Funding (26 states)
  • Stakeholder Impacts, Buy-in (20)
  • Establishing Business Case, Sustainability(13)
  • Lack of Standards (12)
  • Privacy/Security Concerns (11)
  • Legal Issues, Technical Resources & Governance Issues (4 each)

The lessons learned by the states were equally diverse:

  • Collaboration & Engagement (24 states)
  • Time Required (10)
  • Communication & Education (8)
  • Unknown/Too Early & Funding (7 each)
  • Governance, Leadership & Consumer Focus/Involvement (5 each)

Clearly Funding and Collaboration are important. (These are two aspects of health system reform that I am working on in my book project from the perspective of how social and economic forces drive the structure and operations of the US healthcare system.) The importance of the other factors in the Commonwealth report likely depend upon the culture and capabilities of the local health system and healthcare professionals.

The UK National Health Services’ “Choose and Book” system was discussed in the special e-government section in the February 16th issue of The Economist. This system is intended to enable patients and physicians to choose and make appointments for specific services. A couple of bits from this story capture its problems:

  • >50% of physicians surveyed by the British Medical Association said that their experience with “Choose and Book” was negative or very negative.
  • The doctor interviewed for the piece said that only about one in ten of the appointments she makes with the system turns out fine. And it is slow – consuming up to 2 minutes of a 10 minute appointment – making her a “highly paid and expensively trained doctor who is acting, in effect, as a secretary.”

The City of New York’s is launching a new initiative with $60 million to “equip doctors with computer software that can track patients’ medical records in order to provide better preventive care.” This initiative combines electronic medical records and a local health information exchange. Hopefully, the 2-year prep-time they have spent will enable this initiative to be launched smoothly. And it appears that the NYC health commissioner is setting realistic expectations, since his perspective according to the New York Times is that “medical practices will most likely see a decrease in productivity for about six months as doctors’ offices become familiar with the technology and transfer data from paper records or other systems.”

The Department of Veterans’ Affairs in September 2004 scrapped a multi-million dollar computer system when its installation at the VA hospital in Bay Pines, FL – one of the busiest in the VA system – was deemed a failure. This Core Financial and Logistics System was intended to integrate hospital’s clinical operations with its inventory, budgeting and planning programs. However, it either didn’t work as designed or the VA employees couldn’t understand how to use it – as some of the system’s proponents claimed. In either case the result was the same: Productivity dropped as the number of surgeries that could be scheduled declined, and supplies could not be found. This led to Congressional hearings and Federal criminal investigations about how the tens of millions of dollars spent on this system had been used.

The Bottom Line is that while you can spend a lot of money putting in electronic health systems, getting value from them in terms of more efficient care delivery, better prevention or more efficient financial operations depends a LOT on how the systems are designed and how user friendly they are for both patients and healthcare professionals.

Does anyone else out there have interesting experiences or perspectives on electronic health systems?

UK NHS Restricting Access to Uncovered Treatments

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A very interesting article in yesterday’s New York Times discusses how the National Health Service (NHS) in England is clamping down on patients using both their own money and the NHS services to get treatments for the same condition at the same time. The article primarily discusses the case of a woman with breast cancer where the NHS wouldn’t pay for Avastin, and told her if she paid for it herself, she would have to pay for all her medical treatments for breast cancer.

The article also discusses the complexity and apparent confusion within the medical community and the NHS about how this policy is supposed to be implemented. But it doesn’t delve into how this policy would undermine patient-physician communications, quality of care, and the integrity of the medical record. What would happen if a patient knowing that paying on their own for treatments not covered by the NHS could cause the NHS to deny them coverage for this condition. Would they then not tell their physician about this “other” treatment they were receiving? Certainly this could affect the quality of their care and possibly lead to drug-drug interactions. And then if the physician found out about it, how would this undermine their trust in what else the patient told them? And what if the patient decided it was important to tell their physician that they were getting this other treatment, but asked that it not be recorded in their medical record? Could the physician be liable if something happened because of this – possibly because of treatments ordered by another clinician who didn’t know about the “other” treatment not included in the medical record?

This situation reminds me a little of 10+ years ago when patients were reluctant to talk to their clinicians about the complementary treatments – such as acupuncture or herbals – they were be taking. Now it it encouraged for physicians to ask, and patients to tell ,their clinicians about these non-prescription treatments because of the known (and possibly unknown) interactions that can occur with prescription treatments.

It all just makes my head shake and shoulders shudder. But at least I don’t have to wonder why the NHS is adopting this policy – it’s all about money. I guess that they have decided that if a patient can afford to pay for something expensive that the NHS hasn’t approved for them, then they can afford to pay for all of their care for that illness.

And now for the irony. Towards the end of the New York Times article it notes that “…Mrs. Hirst was told early this month that her cancer had spread and that her condition had deteriorated so much that she could have the Avastin after all — paid for by the health service. In other words, a system that forbade her to buy the medicine earlier was now saying that she was so sick she could have it at public expense.”

Any thoughts?