At this year’s American Society of Clinical Oncology (ASCO) conference in Chicago recently, there were a lot of presentations on immunotherapy to treat cancer and tailoring therapies for individuals based on genetic mutations. Abstracts from the conference were recently published on ASCO’s website. The National Cancer Institute announced on Monday plans to launch a national research study sorting cancer patients to treatment groups based on genetic mutations rather than cancer type. This study could lead to drug trials that can be implemented more quickly and possibly match patients with a better suited drug for their cancer. These newer designed studies are referred to as “basket trials”. Click on the link below to a interesting graphic from the Washington Post that illustrates the difference between conventional clinical trials and basket trials.
This past April, two podcasts were released by Freakonomics that took a closer look at randomized controlled trials and taking the approach of “less is more” in taking care of patients. The first podcast interviews Amy Finkelstein, an economist from M.I.T, who has been looking at the utility of conducting randomized controlled trials in studying health care delivery and uses the Oregon Medicaid Health Experiment as an example. In the second podcast, Dr. Anupam Jena (assistant professor at Harvard Medical School) is interviewed regarding a study he led that looked at outcomes in Medicare patients when specialists are away at a conference. Click on the links below to be directed to the podcast from the Freaknonomics website. Thanks to resident Sean Townsend for the reference!
Recently, The New York Review of Books, published online an article written by Dr. Lara Goitein (pulmonologist/critical care board ceritified physician from New Mexico) who discusses the current state of residency training. She makes several references to the book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, written by Dr. Kenneth M. Ludmerer from Washington University. Dr. Goiteini writes of when and where the current model of residency training began with Dr. William Osler and the importance of the mentoring relationship between faculty and the housestaff. Faculty who were held to the highest esteem by peers, residents, and the institution were the ones who were the best teachers. However, with healthcare undergoing major changes and how it’s delivered, Dr. Goitein is concerned about the erosion of this relationship and how residency training is changing. She comments on the recent ACGME guidelines regarding duty hours as well as how the institutions where residents train have changed and its effect on resident education. Check out the article below by clicking on the link! Thanks to several residents who referred to this article for the blog.
This past December in JAMA, Dr. Jeffrey Chi and Dr. Abraham Varghese from Stanford University published an op-ed article in the Viewpoint section titled “The Flipped Patient”. They discuss how electronic health records (EHR) have provided many advantages in care of patients but point out some unintended consequences to training of physicians. Has EHR moved us away from the patient’s bedside? Do we bypass asking about the family history and past medical history because it already auto-populates on the note template? Has the question, “What brings you to the hospital?”, become obsolete with the abundance of information provided in the EHR before you even see the patient? Click on the link below to read the rest the article! Thanks to Dr. Croft and Dr. Kazi for the article reference.
“Ultimately, however, the nature of medicine is the interaction of a vulnerable human being in distress with a caring empathetic team represented by other humans.”
Yesterday the U.S. National Institutes of Health announced the early termination of a trial (START-Strategic Timing of AntiRetroviral Treatment) looking at early treatment of HIV at diagnosis due to clear benefits seen in the study. They recommended patients who learn they are HIV positive should immediately be put on antiretroviral therapy as their study shows a significant survival benefit. The START trial showed that the risk of death or serious illness in patients randomized to early treatment was reduced by 53%. The findings are expected to impact global guidlines regarding HIV treatment. Current W.H.O guidelines recommend treating at CD4 of 500, but acknowledged that treatment at CD4 count of 350 was more practical in many poor countries. They are expected to release updated guidelines very soon. Of note, the CDC recommends immediate treatment at diagnosis of HIV but estimated that 37% of Americans with HIV actually have prescriptions for antiretroviral therapy. Check out the link below from the NIH that summarizes their announcement!
(photo from Susan Sterner/Associated Press)
Doctors called it the black hole.
If their low-income or uninsured patients needed specialty care, they put in a referral to the massive Los Angeles County health care bureaucracy and then waited — for weeks or even months. It could take eight months to see a neurologist, more than three to see a cardiologist.
To speed things up, doctors at county and community clinics urged their patients to go straight to the emergency room, the unofficial back door for specialist appointments. That way, patients could bypass the long waits and get the recommended colonoscopy or CT scan. But that route was expensive and burdensome to ERs.
It’s a problem across the nation: Specialists are hard to find for many patients, and even harder to afford. Sick people may grow sicker as they wait for appointments, causing them unnecessary discomfort and making treatment more costly in the long run. Diabetics may suffer with untreated foot ulcers, raising the risk of amputation; patients with abnormal chest X-rays may turn out to have cancer.
With a million patients a year depending on Los Angeles County for health care, local officials decided they had to act. Hiring scores of costly specialists wasn’t an option. So in 2012 they created a program called eConsult, modeled after a system at San Francisco General Hospital, to streamline the referral process.
In L.A. County, a program run by L.A. Care Health Plan, allows for a Web-based conversation between primary care doctors and specialists that can include the exchange of medical records and photographs. The specialist typically responds to inquiries within three days and a decision on a referral soon follows.
Much as a triage nurse clears the way for accident victims in a crowded ER, clinics would use guidelines for each specialty — created by specialists and primary care doctors working together — to determine who needs an appointment and how quickly. The primary care physicians can continue to care for the remaining patients, consulting with specialists electronically.
Three years later, it’s clear the program hasn’t been a panacea. Most patients in Los Angeles County still need face-to-face appointments with specialists, and there still aren’t enough of them to go around. But both primary care doctors and specialists say things have gotten better.
The county quickly realized its hypothesis was right — about 30 percent of patients referred by providers at county and community clinics didn’t actually need to see a specialist in person. Primary care doctors said they now have a clear way to communicate with specialists about their patients. And when patients do get to the specialist’s office, more have the necessary lab work or tests so the appointments are more efficient.
Overall, doctors agree that the electronic referral system has improved both communication and collaboration among doctors on both sides. And primary care doctors say the new system is far better than the old days, when they would have to “beg, borrow and plead” to get appointments for their patients.
Wait times for specialists in general also have dropped, although a small number of patients with nonurgent health issues still may have to wait up to six months for appointments, according to the county’s specialty care director, Dr. Paul Giboney.
COSTS COULD GO UP
In L.A. County, about 10,000 eConsult requests come in each month across more than 40 specialties. The program has the potential to become a national model: Giboney said health leaders in Illinois, Alaska, Connecticut and elsewhere have contacted him to ask about how the county’s program works.
But some primary care doctors have argued that they don’t have the skills, time or resources to manage patients who need more advanced care. In addition, the system isn’t set up to pay community physicians for the added work, tests or procedures that specialists request before seeing patients.
“Without any extra reimbursement, those costs are hitting the primary care providers,” said Dr. Richard Seidman, chief medical officer at Northeast Valley Health Corp., which runs several community clinics.
EConsult works better for some specialties than others. For example, an endocrinologist may be able to advise a doctor on how to manage the complications of diabetes or a cardiologist can suggest ways to manage a heart murmur but an ophthalmologist can’t treat cataracts through an electronic conversation. Nearly 90 percent of patients referred to ophthalmology end up with an in-person appointment.
Nevertheless, Dr. Lauren Daskivich, an ophthalmologist with L.A. County, said she no longer has to try to interpret one-line referrals and can more easily figure out what type of eye doctor a patient needs to see and how soon. “For the first time, we have actually been able to triage how urgently they need to get in,” she said.
Nationwide, the problem of access to specialists has eased somewhat due to the Affordable Care Act, which enabled more than 16 million people to get insurance. But the health law didn’t cover everyone, most notably people living here illegally, and specialists may not take the insurance that patients have.
Electronic consultation by itself can’t resolve the access problem for poor patients, said Dr. Nwando Olayiwola, associate director of UC San Francisco’s Center for Excellence in Primary Care, who studies these efforts nationally. “It solves a huge part of the problem but it doesn’t solve all of it,” she said.
For now, the Los Angeles County health care system is still overburdened. One doctor put it simply: Technology doesn’t solve the problems that were there before technology.
At the UMMA Community Clinic in South Los Angeles, more than 40 percent of patients remain uninsured and some have been in the queue for a specialist appointment for months. The clinic’s Dr. Cesar Barba says he’s grateful there is a way to talk to specialists and identify those who need to be seen more quickly.
The eConsult system helps, but it “is not the ideal,” Barba said. “The best solution is if we had more specialists. That would be ideal.”
Kaiser Health News (KHN) is a nonprofit national health policy news service.
In a recent article from Nature Communications published on April 28, 2015, Dr. Stephen J. D. O’keefe and his colleagues conducted an interesting study looking at how diet affects mucosal biomarkers of colon cancer risk. They performed 2-week food exchanges in which African-Americans were fed a traditional African diet of high fiber and low fat and Africans were fed western style diet (high fat and low fiber). Colonoscopies were done and biopsies showed less inflammation of the colon and increased production of butyrate, a fatty acid that is thought to protect from colon cancer, in those who ate the traditional African style diet compared to western. Although no direct correlation of diet and colon cancer risk is stated by the authors, the results suggest that diet can have a profound and rapid effect on mucosa which may affect development of colon cancer. Check out the NY Times article below as well as the abstract and original article from Nature Communications and thanks to Dr. Bedimo for the reference!
African Diet May Lead Away from Colon Cancer (NY Times)
Fat, fibre, and cancer risk in African Americans and rural Africans (Nature Communications)
Rates of colon cancer are much higher in African Americans (65:100,000) than in rural South Africans (5:100,000). The higher rates are associated with higher animal protein and fat, and lower fibre consumption, higher colonic secondary bile acids, lower colonic short-chain fatty acid quantities and higher mucosal proliferative biomarkers of cancer risk in otherwise healthy middle-aged volunteers. Here we investigate further the role of fat and fibre in this association. We performed 2-week food exchanges in subjects from the same populations, where African Americans were fed a high-fibre, low-fat African-style diet and rural Africans a high-fat, low-fibre western-style diet, under close supervision. In comparison with their usual diets, the food changes resulted in remarkable reciprocal changes in mucosal biomarkers of cancer risk and in aspects of the microbiota and metabolome known to affect cancer risk, best illustrated by increased saccharolytic fermentation and butyrogenesis, and suppressed secondary bile acid synthesis in the African Americans.
This week Dr. Atul Gawande, professor at the department of surgery in Harvard Medical School, wrote an article in The New Yorker, “Overkill”. He discusses potential consequences with ordering too many tests that may be unnecessary and how it contributes to high cost and decreased value of health care. Interestingly, he argues that even the correct diagnosis doesn’t lead to good outcomes all the time. He discusses how “overdiagnosis” can lead to anxiety and stress on the patient’s end and even more tests, procedures, and costs. Dr. Gawande uses examples from his own personal life and colleagues that illustrate how much harm can happen when not appreciating the actual value of the care we provide. He even refers to the Texas town of McAllen and the remarkable change the hospital systems and providers have undergone in a positive way since writing his well publicized article in 2009, “The Cost Conundrum.” Thanks to Dr. Kazi for bringing this to our attention! Check out his article below by clicking on the link.
(Image is illustration by Anna Parini featured in May 11, 2015 issue of The New Yorker)
“Shared decision making” is a term we often hear and referred to in health care as patients have become more educated about their health and want to be informed when making medical decisions. With recent spotlight in the media and medical literature on utility of tests and treatments, patients have even more questions for their providers. There is a resource for patients who want to know more about tests and treatments from the Informed Medical Decisions Foundation. This website provides links and articles that help guide a patient through clinic visits and what questions they may want to ask their provider. Also, there are links to online tools such as the cardiovascular disease risk calculator that patients can use. Thanks to Dr. Ethan Halm from the division of General Internal Medicine at UT Southwestern for the reference!