Tuesday, January 3, 2017

Home Hospitalization – An Innovative and Transformational Approach Whose Time Has Come



American healthcare delivery is seriously dysfunctional. It takes you about three weeks to get a doctor’s appointment, you sit in the waiting room for a long time, you get 10 to 12 minutes with the doctor and then you have a hefty deductible and/or copay despite paying handsomely for insurance. American medicine costs about three times per capita more than most other developed countries yet outcomes are no better, patient satisfaction is low and burn out among physicians is high.

As to hospitalization, it is very expensive, the risk of a medical error is real, hospital acquired infections are all too common and the patient frequently leaves feeling unsatisfied.

But do all those individuals admitted necessarily need hospitalization? Today the answer is generally yes. But tomorrow that could and probably could change, for the better. What if many of the attributes of the hospital could be brought to the home? Attributes like nursing care, electronic monitoring of vital signs and intravenous therapy, to name just a few. There is really no reason why the home cannot serve this purpose for some selected patients today. When it does, the patient remains in familiar, comforting surrounding; the chance for errors and infections can go down and the costs of care can decline substantially. The critical question, of course, is whether the clinical outcomes are just as good, or possibly even better.

Enter an innovative and exceptionally transformational approach. Think of it perhaps as a virtual hospital that maximizes the capacity to use today's digital technology.

Embryonic at best in the United States, there are multiple examples worldwide as recently reviewed in the New England Journal of Medicine. The basic idea is to follow emergency room evaluation (or even doctor’s office evaluation) with the decision to admit to the hospital or to use hospital at home care. Not all patient conditions are appropriate for home care of course but among those that are often appropriate: exacerbation of heart failure and chronic obstructive pulmonary disease, community acquired pneumonia, asthmatic attacks, deep vein thrombosis and possibly pulmonary embolus and deep-seated skin or soft tissue infections.

One recent study compared 50 patients treated at home for a 34 day period to a similar group treated in the hospital after initial evaluation in the emergency room or observation unit. At the conclusion of the study period, the hospital at home patients had greater satisfaction with multiple query categories and met standard quality measures for their specific diagnoses.   Those patients were less likely to need readmission over the ensuing ninety days.

Some keys to success include effective two-way digital communication systems that allow for virtual physician and nurse visits in an HIPAA secure setting along with remote virtual biometric monitoring. Proper patient selection is important as those who might need more intensive diagnostics (e.g., MRI) or therapeutics (e.g., surgery) are inappropriate candidates. It is also important that the work traditionally done by hospital personnel not be offloaded to the family members; this will defeat the purpose and lead to ill-will. Maintaining contact virtually and with home visits for a prolonged period after the immediate acute episode will likely improve the care transition and lead to fewer readmissions.

With positive results nationally and internationally, why hasn't the hospital at home model become commonplace? I suspect it has multiple causes not least of which is physician concern. Medical professionals are loath to make dramatic changes when the current system works, or at least works reasonably well for most episodes. Add in, of course, that the fee-for-service reimbursement model for physicians and hospitals discourages interest. Only when the physician can be paid for virtual/digital care approaches and the hospital benefits financially from fewer admissions will real interest develop.

Innovative? Certainly. Transformative? Definitely. Makes sense from a quality of care perspective? Yes. Leads to greater patient satisfaction? Yes. Means fewer safety lapses and care associated infections? Perhaps. Reduces unplanned remission rates? Probably. Costs less? Yes.

In sum, the time is right for implementation in those settings where payment models do not discriminate against in-home care models. Logical places to start would be Medicare Advantage plans, military or veterans plans and other entities that hold total fiscal and care risk.


Home hospitalization could be one step in improving the American dysfunctional healthcare delivery system with improved care, greater satisfaction and reduced costs – the Triple Aim

This was first published at Medical Economics December 19, 2016 


Thursday, November 17, 2016

Gluten - It's Not Just The Bread - 2



There are three (possibly more) illnesses caused by gluten - celiac disease, gluten allergy and gluten sensitivity.

There are no medicines or pills to take. Whether it is celiac disease, allergy or gluten sensitivity, the only effective approach is to totally avoid gluten. This is relatively easy to do at home but it can be more complex eating out. Gluten is obviously in products made from wheat flour like bread, pasta, pizza, pretzels, pies and cakes. At home it means getting rid of the obvious - white or whole wheat flour, pancake mix, cake and cookie mixes and many cereals like Wheaties. More difficult to recognize are pantry items that have gluten lurking in them that might surprise you. Cheerios and Corn Flakes include wheat flour. Soy sauce usually is made of both soy and wheat although wheat-free soy sauce is available.  Worcestershire sauce is a problematic item; some brands are gluten-free while others are not. Malt vinegar is made from barley and so is not gluten-free; white vinegar may be not be gluten free whereas balsamic and apple cider vinegar are usually safe. Beer is brewed from wheat and barley. Hard liquors are often made from wheat but are distilled and so are generally gluten free.  Seasonings can be a complex problem; some seasonings may use wheat to stabilize the spice or herbs in it.
Basically, it is a process of reading the labels carefully. Food package labeling has improved immensely in recent years and can be a real blessing in the grocery store. The ingredients label must note if it contains wheat.
If you follow the basic very healthy Mediterranean style diet you can reasonably easily remain gluten free. The Mediterranean diet is fundamentally one based on a fresh vegetables, simply cooked, multiple fruits, legumes such as beans and lentils and modest size quantities of meat, poultry or fish plus olive oil along with nuts and seeds and wine in moderation.

It's easy to prepare food from scratch but in our society we don't tend to do that anymore. Most foods come processed and pre-packaged; often those forms are adulterated with substances that include gluten. That's why the label reading is very important. But far better to start with fresh ingredients from the produce, meat and fish sections and prepare them in a way that doesn’t use gluten.

Eating in a restaurant is more of a challenge. There you're not in control of the ingredients used. As for everyone, ordering meals based on fresh prepared vegetables and fruits along with high quality meats, poultry and fish is best. Then the question is whether the chef used any added gluten-containing ingredient such as in the seasoning or marinade. Gravies are often thickened with flour as are many soups.  Eggs of course are gluten-free so you might expect that an omelet will be gluten-free even if you add veggies such as spinach, tomatoes and perhaps some cheese. But it may not be. Why? It's because some of the commercial prepackaged omelet mixes include a bit of pancake batter to make the omelet a bit smoother and fluffier. Something you would probably never guess. But if you are gluten sensitive, your GI tract will figure it out a short while later with disturbing symptoms.

Even a restaurant meal free of gluten might have been prepared next to a gluten containing meal leading to cross contamination.  So it is critical that the restaurant know your requirements and be prepared to assist.
The food industry has jumped on the gluten free bandwagon in a major way. They see market potential. It is now a multi-billion dollar per year market and growing. Why so much? Many people have started to go gluten free even though they are not sensitive nor have celiac disease. They believe that they do or will feel better by avoiding gluten. Of course this means that there are more and more gluten free products on the grocery shelves now for those that must be gluten free. Unfortunately, the food manufacturers that have produced so much gluten free food are not necessarily manufacturing healthy foods. A food product may be gluten free but processed to contain high levels of salt, fat and sugar – hardly healthy. Once again, read the label, this time for the calorie count, the fat content, the added salt and sugar.
Here is the bottom line. For a sizable portion of the population, gluten is a toxic substance. Celiac disease is very serious. Gluten allergy although uncommon can be devastating. Gluten sensitivity, while not life threatening, can be very life altering in a most negative way. Unfortunately because the symptoms of celiac or sensitivity are not necessarily GI related, the diagnosis is often elusive. For those with gluten-related disease the only treatment is preventative – completely avoid gluten. 

What should you do? If you are gluten sensitive, then you need to avoid gluten. If you have celiac disease this is especially important, indeed critical. If you are gluten sensitive you'll be most uncomfortable if you eat anything containing gluten.  The degree of discomfort and the length of the discomfort will probably depend upon how much you eat at any given time. So the key is to avoid it. But before you try to diagnose and treat yourself, talk to your doctor; that is essential. Your problem may or may not be gluten; it’s too important to leave to chance.



Gluten - It's Not Just The Bread - 1




Gluten is a mixture of proteins found in wheat, rye, barley, spelt, kamut and a few other grains. Gluten which means glue in Latin is the substance that gives bread its texture and elasticity. It's what gives bread that sticky pull which is so nice when you break a good French baguette; it's what gives a muffin its spongy characteristic and it helps form those little cells in warm bread that soaks up butter.
Gluten is not found in rice, corn, quinoa, amaranth or tiff. Despite its name, buckwheat does not contain gluten. Oats are gluten free but often raised near wheat or processed in mills that also grind wheat so they can be and often are cross contaminated.

There are three (possibly more) illnesses caused by gluten - celiac disease, gluten allergy and gluten sensitivity. Celiac disease is a serious life-modifying and often life-threatening disease. It is an autoimmune disease meaning that gluten sets up a reaction in a predisposed individual such that the body attacks its own cells. Not only can it cause gastrointestinal damage leading to malabsorption but it can lead to problems in multiple other organs in the body. Previously rather uncommon with no more than one person in 300 having the disease, today about 1% of Americans have celiac disease and the incidence appears to be rising still. It occurs in people who have a genetic predisposition, these being about one third of the population. But within that group of predisposed individuals, only some will develop celiac disease for reasons that remain unclear.

Gluten allergy is uncommon, affecting less than 1% of the population. It's an allergy similar to how some people develop G.I. symptoms from, say, shellfish. Usually the reaction comes on quickly after eating, can be quite severe often with abdominal pain, nausea, vomiting and diarrhea. The reaction stops once the offending allergen (gluten) has passed out of the body.

Gluten sensitivity (or gluten intolerance) affects perhaps 10% and possibly more of the population. It ranges from rather mild to quite severe. The most common symptom is abdominal discomfort ("bellyache," nausea, bloating) in two thirds of affected individuals. The next most common symptoms do not relate to the GI tract – eczema, “foggy mind,” headache and fatigue, all occurring in about a third of individuals. One third develop diarrhea when they eat gluten. Other less common symptoms are depression (20%), anemia (20%), numbness in hands or feet (20%), acid reflux and joint pains in about 10%.  The severity of the symptoms seems to depend upon how much gluten is ingested at one time. The more one eats, the worse the symptoms. For some people the symptoms dissipate within just a few hours but, for others, problems such as diarrhea, reflux or even abdominal discomfort can persist for days or even weeks.

In a continuing care retirement community of about 2000 residents where I live, Charlestown probably has about 20 with celiac disease, a few with gluten allergy and 200 or so with gluten intolerance/sensitivity. Many will not be aware of the connection between their symptoms and gluten ingestion. The diagnosis is often missed by physicians because the symptoms can be vague. Many problems cause abdominal discomfort and many of the symptoms of gluten associated disease are not related to the GI tract, such as headaches or rash.

There are no medicines or pills to take. Whether it is celiac disease, allergy or gluten sensitivity, the only effective approach is to totally avoid gluten.

 

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).