Summer 2021
PMH STORY
The subscriber had spent the last six weeks in a nursing home. This nursing home used a medical director system: Physicians were paid and contracted to provide the resident’s care. The nursing home did not accept orders from outside doctors.
The PMH doctor came to see his resident. He had seen her several times before and had a good relationship with the medical director. During this visit, a nurse came in the room and reported a fall two weeks previously, sliding to the floor. She felt that the patient was trying to move too much trying to get out of the chair. The medical director had started routine Xanax. The nurse said the Xanax was not strong enough, and we needed to increase the dose.
As the PMH doctor listened to the nurse, he noticed the resident getting a look over her face, staring out the window, no longer engaged. When the nurse left the room, the PMH doctor shut the door and listened to the resident: she reported that the staff were not listening to her and were not being helpful. She wanted to go home.
The family had provided a sitter to be with her during daytime hours. The patient was sitting in a wheelchair, and the PMH doctor then said, “Let’s explore.”
They went down two long hallways checking out the facility, greeting the nurses and going to the Nurses’ Station. They then went out to a patio. “Oh, I haven’t been here.”
When on the patio, she met another resident, a man that she had known for years, who was sitting there with his son. Her joy and liveliness were a breath of fresh air. The son of the man said, “I knew her before she came here, and she is such a wonderful Person.”
The PMH doctor encouraged the caregiver to take the patient out of the room several times every day to explore, move, and to give her mobility that she does not have any more in her own legs. Dr. Kelly contacted the medical director and reported “the Xanax isn’t working: The nurses say she is getting no better at all,” and gave the doctor the report on the travels about the nursing home and plans to help the patient with her desire for more mobility and activity.
The PMH doctor had time to listen and explore. With PMH, the doctor has the time to understand better the problems faced by the nurses, the caregivers, the resident, and the doctors.
Allan R. Kelly, MD FACP
COST OF CARE
William C. Roberts has been an internist and a leader at Baylor University Medical Center in Dallas for decades. He writes about medical costs in a recent BUMC Proceeding essay.
His review of the cost of a cesarean section looked at charges at Memorial Medical Center in Modesto, California. This is a large hospital, busy with cesarean sections.
The charges for routine cesarean sections with brief hospitalizations ranged from $6000 to $60,000, and the cost appeared to be determined by the insurance plan of the patient. Dr. Roberts tells the story of his own family: “One of my granddaughters recently had a C-section and rather than paying the higher cost using her private insurance, she and her husband paid the smaller price by paying cash. Money tends to lose meaning when it is connected to medicine.”
In our office we also see examples. This summer a patient called from x-ray. His co-pay for his insurance for a CT scan of the abdomen was to be $2500. He hesitated to make such a large payment because he didn’t really know what a CT scan might cost.
We quickly called Envision Radiology to check on their cash price: $595. We told the patient his choices, and he went for the cash price.
We see this with medications as well. The difference in price can be not only a factor of 10, but a factor of 100. Nobody wants to spend $100 when they can get the same care for $1.
We continue to study this problem. We encourage our patients to look into the costs, and to shop for a better price. That is true for our office as well. If you need our help, just call and we will see what we can do to find out your options.
Allan R. Kelly, MD FACP
STATINS AND ELDERLY AMERICANS
Ever since evolution of statin therapy to reduce cardiovascular mortality, there has been uncertainty about statin benefits for the elderly. All the early statin prevention trials focused on younger people, even as young as 40.
For decades, the American Heart Association and other organizations advised that they could not endorse the use to statins in adults over the age of 75 or 80 because of limited information. Over the past 10 to 20 years, adults aged 80’s and 90’s, had doctors recommend discontinuation of statins.
There are two areas of research that may change that approach. First, the VA Medical Center published data in JAMA looking at adults over the age of 75-90, and how statin use affected death and serious adverse cardiac events. The study looked at veterans who had no history of atherosclerotic disease and no past or present use of statins in their VA charts. Then they studied healthy veterans who were initiated on statins and compared their outcomes to healthy veterans who were not initiated on statins. This is an observational study, and prone to confounding. But the results are important.
Healthy veterans started on statins after age 75 had a 20- 25% reduction in overall mortality during the 7 years of the study. The data held for women as well as men.
Reductions in cardiovascular death alone could not account for larger reductions in overall death.
Second, Baylor Scott & White is leading a randomized control study, the PREVENTABLE Trial to understand this even better. They will randomize adults over age 75 who are in good health and who have no heart disease, dementia, or disability, to statin or placebo. They will follow participants for five years, testing cognitive and physical ability, and monitoring for major adverse cardiac events as well as all causes of death. If you are interested in volunteering, call (888) 507-3732.
Allan R. Kelly, MD FACP
MEDICINE PRICES AND PMH
Pricing is unpredictable even for common problems. [For example, post-menopausal symptoms are common.] Treatments include oral estrogens, topical estrogens, transdermal estrogens, and selective serotonin reuptake inhibitors.
Plain estrogen or Estradiol is available as a generic pill. At Good RX, the cost was $0.90 per month. Topical estrogen Imvexxy cost $572 per month. There is something odd about a situation where medical treatment (estrogen) can be purchased for either $572.00 per month or $0.90 per month.
In the non-estrogen category of post-menopausal treatment, there was only one drug approved by the FDA. Paroxetine, also called Paxil, was approved by the FDA to treat menopausal symptoms at a dose of 7.5 mg. The monthly cost on the 7.5 mg pill is between $150.00 and $211.00. But if one were to purchase a 30 mg Paxil tablet and just take a quarter of a pill (or ask a pharmacy to make an 8 mg capsule) the cost would also be less than $1.00 per month. The FDA-approved product costs $211.00 and the simple modified available product costs less than $3.00 per month.
When faced with medication cost that we find burdensome, there will often be an option.
The option may not be an FDA-approved form of a product. Cutting the pill or having a pharmacy compound a capsule can save a lot of money. With ingenuity, we can control Costs.
Robert H. Kelly, MD FACP
GENERAL VERSUS REGIONAL ANESTHESIA
A recent report compared dementia risks from general anesthesia (GA) versus a regional anesthesia (RA) for matched surgeries in Ontario 2007 to 2011. The patients were followed for about five years after the procedure. General anesthesia involved both inhalation and intravenous anesthetic agents. Community-dwelling older adults without dementia and at least 66 years old underwent one of five surgical procedures:
hip surgery, hernia surgery, knee surgery, hysterectomy, and prostate surgery. A total of 41,000 divided between general GA and RA. The preoperative risk measurement was slightly higher in the RA group suggesting a higher frequency of emergency surgeries. However, high risk issues such as head trauma, stroke, and diabetes were more common in the GA group.
Over the course of five years approximately 6% of patients in both groups developed dementia. Previous studies had shown an incidence of dementia on the order of 23% and this increase in the overall risk of dementia was noted in both anesthetic groups. GA did not increase dementia risk.
Postoperative delirium was a problem especially in those who used alcohol preoperatively. It is best to discontinue all alcohol and all smoking at least two weeks before surgery. But long-term cognitive effects appear low.
Surgeries studied here are low-risk surgeries. High-risk surgeries, such as heart surgery and brain surgery, are more likely to be associated with confusion or delirium, not because of the anesthetic, but because of the underlying disease processes.
Robert H. Kelly, MD FACP
KETOGENIC DIET AND COGNITION
An experiment was done in 50 to 90-year-old patients with Alzheimer’s disease. The experiment revolved around reducing carbohydrates in the diet and pursuing a ketogenic diet or a diet low in carbohydrates. Twenty-one patients were studied.
Performance and activities of daily living (the usual activities of life) were used as the outcome variable. Compared with usual diet, patients on a high-fat, low-carbohydrate diet had a distinct improvement in measured components of independence.
Cardiovascular measures were improved. There was mild increase in cholesterol, although mostly of HDL “good” cholesterol. The study concluded after only two weeks. In this trial, a low carbohydrate diet was better for the brain.
Robert H. Kelly, MD FACP
QUOTES
“I can tell you I’d rather have a doctor that understands my concerns and listens to me than one who scored in the 99 th percentile in their standardized exams but never questions the diagnosis.”
Ashley Brodrick, Medical Student, 2021
“All medical knowledge has a half-life. We no longer prescribe arsenic for syphilis or milkweed for pleurisy: but we do need physicians with a curiosity and discipline to continue their learning.”
Benjamin Doolittle, M.D., 2021
“The EHR, which was intended to improve patient care, has had the ironic and unintended consequence of impairing practice efficiency largely because of poor design, they focus on regulatory reporting and burden is placed on clinicians by data Entry.”
Yumi DiAngi, 2017
“For many physicians, listening has become a luxury squeezed out by time constraints, the demands of electronic health record and the countless metrics demanding our attention. Somehow in our efforts to systemize all we know (and make it profitable), the centrality of the doctor-patient relationship got lost.”
Lisa Rosenbaum, M.D., 2021