I hope you all enjoyed morning report today - we covered a variety of topics, and had some very interesting discussion - thank you all for participating! As Dr. Bell mentioned, so many of these topics interested me that I almost don't know where to start, but I will try to contain myself, and keep this concise.
We discussed a man with EtOHism and RA who presented to ER confused after being prescribed diazepam for insomnia.
1. Drug safety: We must always think about prescribing safety when discharging patients from hospital, and as we know there are certain medications that are known to be associated with morbidity and mortality, particularly in the elderly. There are many examples of this, but we have several 'local' studies looking at this: - Arch Intern Med 2008; 168(10):1090-6. (Dr. Bell's on this) found that relative to those who received no antipsychotic therapy, community-dwelling older adults with dementia who were newly dispensed an atypical antipsychotic therapy were 3.2 times more likely and those who received conventional antipsychotic therapy were 3.8 times more likely to develop any serious event (defined as event requiring hospital admission or death) during the 30 days of follow-up.
- CMAJ 2009; 181(12):891-6 (Dr. Dhalla's on this) looked at long-acting oxycodone prescribing, and found that from 1991 to 2007, prescriptions of oxycodone increased by 850%. Opioid-related deaths doubled, from 13.7 per million in 1991 to 27.2 per million in 2004. The addition of long-acting oxycodone to the drug formulary was associated with a 5-fold increase in oxycodone-related mortality (p<0.01).
2. Publicly funded healthcare: Our discussion of why this patient presented to the ER led to a discussion about primary care, and what the effect of disincentives (ie user fees) would have been on this patient. (I will state my conflicts of interest here - I am pro-medicare). Dr. Bell mentioned the RAND Health Experiment, which looked at 4
randomized insurance models: full coverage, and 25, 50, or 95% cost-sharing (or
copayments, the % being the percentage of medical costs that the patient has to pay). You can see why this study is cited by pro-privatization groups: there was fewer usage of health services by people who had to pay, and no significant difference was found in quality of care (defined as process measures decided upon by the analysts, potentially introducing some bias?). HOWEVER, you can also see why this study is cited by pro-medicare groups: highly effective services were underused just as much as less-effecitve services, and the quality of care in some ares DID suffer: free care led to improvements in HTN, dental health, vision, and other serious conditions (exertional CP, bleeding, LOC, unintentional weigh loss). The poor disproportionately experienced poorer quality of care in these areas. I am attaching a summary document on this study.
Another resource if you are interested in some of the evidence for publicly funded health care can be found at http://www.canadiandoctorsformedicare.ca/mustreadjournals.html
A particularly interesting article: Increased Ambulatory Care Co-payments and
Hospitalizations Among the Elderly, Amal N. Trivedi, Husein Moloo and Vincent Mor, The New England Journal of Medicine 362(4): 320-328, 2010.
Essentially, enrollees in plans that increased their copayments had significant increases in annual in-patient days, annual patient admissions, and the probability of any use of in-patient care, and were more likely to be black, of lower socioeconomic status and lesser educational attainment.
See http://www.canadiandoctorsformedicare.ca/e-rounds/e-rounds26.html for a more complete analysis.
3. Lastly, ascites. We'll have lots of time to talk about the physical exam so Ill send you that article later on (JAMA rational clinical exam). We discussed the role of albumin in cirrhotics with spontaneous bacterial peritonitis. A NEJM RCT of 126 such patients randomized to either IV cefotaxime alone or IV cefotaxime + albumin iven at a dose of 1.5 g per kilogram at the time of diagnosis, followed by 1 g per kilogram on day 3, showed that the group given albumin had less renal impairment and death up to 3 months out. Here's the study.
randomized insurance models: full coverage, and 25, 50, or 95% cost-sharing (or
copayments, the % being the percentage of medical costs that the patient has to pay). You can see why this study is cited by pro-privatization groups: there was fewer usage of health services by people who had to pay, and no significant difference was found in quality of care (defined as process measures decided upon by the analysts, potentially introducing some bias?). HOWEVER, you can also see why this study is cited by pro-medicare groups: highly effective services were underused just as much as less-effecitve services, and the quality of care in some ares DID suffer: free care led to improvements in HTN, dental health, vision, and other serious conditions (exertional CP, bleeding, LOC, unintentional weigh loss). The poor disproportionately experienced poorer quality of care in these areas. I am attaching a summary document on this study.
Another resource if you are interested in some of the evidence for publicly funded health care can be found at http://www.canadiandoctorsformedicare.ca/mustreadjournals.html
A particularly interesting article: Increased Ambulatory Care Co-payments and
Hospitalizations Among the Elderly, Amal N. Trivedi, Husein Moloo and Vincent Mor, The New England Journal of Medicine 362(4): 320-328, 2010.
Essentially, enrollees in plans that increased their copayments had significant increases in annual in-patient days, annual patient admissions, and the probability of any use of in-patient care, and were more likely to be black, of lower socioeconomic status and lesser educational attainment.
See http://www.canadiandoctorsformedicare.ca/e-rounds/e-rounds26.html for a more complete analysis.
3. Lastly, ascites. We'll have lots of time to talk about the physical exam so Ill send you that article later on (JAMA rational clinical exam). We discussed the role of albumin in cirrhotics with spontaneous bacterial peritonitis. A NEJM RCT of 126 such patients randomized to either IV cefotaxime alone or IV cefotaxime + albumin iven at a dose of 1.5 g per kilogram at the time of diagnosis, followed by 1 g per kilogram on day 3, showed that the group given albumin had less renal impairment and death up to 3 months out. Here's the study.
Phew! That's all for now!
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