Summer 2022

PMH STORY

In making rounds at the hospital, a great day is when the patient gets to go home. It is also a time when I reflect on what PMH is trying to do.

At discharge, we need to “reconcile” the medication list from the hospital with the patient’s pre admission medication list to identify needed home (discharge) medications. This process depends on the accuracy of the computerized pre admission list. It depends on the physician’s knowledge of the patient’s medical problems. It depends on communicating with the family about things like where to send the prescription, and who to call if there is a problem.

When the outpatient physician is also seeing the patient in the hospital, I believe errors and confusion are minimized. The doctor already has the pre admission medication list. The doctor is able to talk to the family and the patient about the discharge process, the discharge medications, and the discharge follow-up. The physician already knows which pharmacy the patient uses and can confirm it during rounds.

Most importantly, of course, the family knows who to call. The same doctor who saw the patient in the hospital would be responsible for the medications at home the next day and will be responsible for that medication list on follow-up in the doctor’s office. For patients and family members, medication lists are complicated. I remember trying to take care of my own parents. It was not easy to understand what medications they are supposed to be on in transition from hospital to home. These transitions are complex for family caregivers, patients, and doctors. Having a doctor involved with both the inpatient and the outpatient care will make this transition better.

Allan R. Kelly, MD, FACP

FALLS AND AGE

65 is the age when Medicare starts, and the Center for Medicare Service is interested in the health experience of its enrollees. The Current Beneficiary Survey has been done since 2010, recording health outcomes. In the 2017 survey, 45% reported a fall. Most of these falls did not result in significant injury.

Falls cause problems for people of any age. We should all be aware of steps that may reduce risk of falls:

1. Exercise daily for at least 10 minutes.
2. Reduce or eliminate alcohol.
3. Report falls to your doctor.
4. Balance classes at a local gym or YMCA, like Tai chi.
5. If you have a serious fall, work with a physical therapist. Your doctor can write a prescription and Medicare will cover the cost.
6. Make sure your home is safe. Look for places to put handrails, grab bars or other devices. Make sure the surfaces are flat and there is nothing on which to trip. Repair trip hazards before you fall or fall again.

Allan R. Kelly, MD, FACP

HEALTH AND SLEEP APNEA

Researchers in Spain studied 89 men with severe obstructive sleep apnea (OSA). The men were randomized to two groups.

The intervention group vigorously addressed nutritional change, moderate aerobic exercise for 20 minutes 5 days per week, smoking cessation, alcohol avoidance and sleep hygiene with weekly discussions lasting 60 minutes. The control group had a one time 30 minutes session to discuss these changes in lifestyle. Average age was 54. Average weight was obese — BMI 34.

After six months, there was substantial improvement in the treatment group versus no change in the control group. After six months, in the treatment group, 29% of patients experienced complete remission of OSA and 60% no longer required CPAP. On the contrary, in the group without intervention, there was no improvement in the OSA scores or severity.

This adds to the understanding that consistent nutritional change, daily exercise, and non-use of alcohol can often effectively treat sleep apnea. There is nothing wrong with using sleep apnea equipment. Not everyone’s sleep apnea is related to nutritional or dietary habits, but a person with sleep apnea whose body mass index is greater than 30, who is using alcohol and who is not exercising owes it to their well-being to address these issues. The goal is eliminating, or reducing, the burden of sleep apnea.

1. Diet and weight loss.
2. 15 minutes of exercise daily.
3. Discontinue tobacco.
4. Discontinue alcohol.
5. Good sleep hygiene.

Robert H. Kelly, MD FACP

HIP SURGERY, ANESTHESIA, AND DELIRIUM

In persons older than 80, delirium after surgery is too common. Delirium is when there is confusion and the ability to attend and remain oriented in the environment in lost or severely impaired for a period of time. With recovery from the trauma, pain, and immobility of surgery, postoperative delirium will resolve. Delirium is a marker of injury and a prognostic sign of potential increased risk of dementia in the future. Whether delirium is the cause of that increased risk or another sign of underlying impairment already present is not known.

A study was done of 940 patients in China who had suffered a fall with hip fracture. The patients were randomly assigned to receive either general or regional anesthesia. Was there a difference in the rate of delirium?

In the regional anesthesia group, (spinal anesthetic, nerve block, and sedation), 6.2% developed delirium, whereas in the general anesthesia group, 5.1% developed delirium. Length of hospitalization was the same. Death was more common in the regional anesthesia group (8 compared to only 4 in the general anesthesia group). Other researchers have also shown that general anesthesia is reasonably safe compared to regional anesthesia.

The best course of action for a person who has suffered injury and requires surgical repair is to follow the recommendations of the surgical team. It is prudent for that team to use tools, including the anesthetic approach, that they are most familiar with and are convinced are most beneficial for their patients. If the recommendation is for general anesthesia, you can be confident that it will not worsen the risk for delirium as you Recover.

Robert H. Kelly, MD FACP

NARCOTICS – MORE BAD NEWS

The CDC reports changes in narcotic pain use in the United States. Regulatory agencies and medical societies have urged reduction in opioid prescribing. Prescription narcotics were responsible for one-third of the 100,000 narcotic drug overdose deaths in 2021.

A CDC study looked at emergency department narcotic prescriptions. Narcotic prescriptions increased from 19% to 21% from 2006 through 2011. Reversing the trend, from 2011 to 2016, narcotic prescriptions decreased to 15% of emergency department visits. The new CDC study showed that narcotic prescription at the hospital for headache and migraine reduced by 98% and for back pain have fallen by 50%. In 2012, the CDC and the American College of Physicians published a policy that include a recommendation against routine prescribing of narcotics for back pain and migraine. Apparently, it was possible to reduce narcotic use by 98% when it comes to relieving back pain. There is this great experiment ongoing where what used to be right (narcotics for common pain complaints) has now been shown to have probably been 98% wrong.

Robert H. Kelly, MD FACP

PRIVATE CAREGIVERS: SIMPLE IS BEST

Does reporting improve home care by private caregivers? We know that in-home caregivers (who are not nurses) can help the frail elderly remain at home successfully. We know such care can be a boon for the family. Private home-based care is generally not covered by Medicare but is provided by families for their loved ones. “Right At Home” is a national home care provider with many franchise offices. The researchers at Harvard collaborated with the company to randomly assign franchises to an enhanced monitoring program designed to report changes in condition or to continued non-reporting status. Generally speaking, our caregivers do not report changes in condition to doctors or hospitals. They work with the family in many ways to help the patient, and the family decides when to call. In this research, a cell phone-based app was introduced into different franchises at separate times. The app would call upon the caregiver to report to the office changes in condition by responding to specific queries on the screen or keypad.

The intervention was called “Home Care To Improve Health Outcomes,” or “In-Home.” It was based on the idea that by introducing additional software and reporting, home caregivers could reduce the rate of hospitalization or death. The experiment ran from 2015 to 2018 and involved 269 franchises. 738,000 person months and 103,535 individuals. Across all regions, there was no difference in emergency room visits, hospitalizations, or rates of death with the In-Home program. There was, however, an increase in cost and time required by caregivers to do their work. The extra cost was, of course, paid in hourly wages by the families.

The authors write: “Our randomized evaluation of the In-Home Intervention found no impact on the primary outcome nor evidence of impact on hospitalization, ED visits, or mortality.” The authors go on to say that even when they “focused on subgroups in which we thought engagement might be stronger and better, there was no difference.” In other words, even cherry picking the groups they thought would benefit, they found no benefit of increased complexity in ordinary care. We’ll keep it simple for now. Mandatory reporting had no value.

Allan R. Kelly, MD FACP

QUOTES

“Julia didn’t like the way the news was delivered, by a doctor she didn’t know well. The doctor left the door open as she spoke to us. The doctor didn’t even sit down. So, I was upset this morning.”

Adeline Goss, M.D, 2022

“Throughout medicine, patients and clinicians alike are feeling the absence of robust therapeutic relationships.”

Caleb Gardner, M.D., 2020

“With every clinical encounter, it became clear that my goals for providing the best patient care and my goals for looking good were completely misaligned. What people really need is a doctor who can look at them, not the screen, to figure out what's actually going on.”

Lisa Rosenbaum, M.D., 2022

IMPORTANT CHANGE

Nurse Practitioner Claire Kelly-Legler is moving to Tulsa, Oklahoma with her family, and she will no longer be working in our clinic. We are excited for her new chapter in life and wish her all the best in her future endeavors.