Friday, January 27, 2012

Unnecessary Medical Practices

Modern medicine effectively incorporates a multitude of tests and procedures to improve the health of patients. However, an estimated $500 billion a year goes toward unnecessary medical practices - tests, procedures, and treatments - that do not benefit patients. "Promoting Good Stewardship in Medicine" is a project of the National Physicians Alliance that identified a number of unnecessary practices found in primary care practices. The following seven practices topped the list:

Imaging studies for low back pain. Low back pain is the fifth most common reason for seeing the doctor, accounting for thousands of visits to primary care physicians each year. In most cases, low back pain is due to injury or overuse of muscles, ligaments, and joints - problems that don't show up on imaging studies such as x-rays, CT scans, or MRI scans. The vast majority of acute low back pain will resolve on its own within a couple of weeks and performing imaging studies contributes almost nothing to treatment outcome. Exceptions to this are back pain lasting longer than 6 weeks or the presence of "red flags" suggesting a more serious cause. These include neurological deficits, such as urinary incontinence, signs of infection (fever, chills, etc.), a significant injury, or a history of osteoporosis.

Blood chemistry panels in asymptomatic patients. In healthy individuals, performing complete chemistry panels (electrolytes, blood sugar, liver functions, kidney tests, etc.) rarely provides helpful information to assist in patient management. This is true for screening urine tests also. Testing for abnormal lipids (cholesterol, triglycerides, etc.), however, is likely to turn up abnormal results in a significant number of asymptomatic individuals. This provides an opportunity to address an important cause for heart disease and stroke that often remains "silent". Another blood chemistry test that has been shown to be beneficial is screening for elevated blood sugar, an indication of diabetes, in hypertensive patients.

Electrocardiograms in low risk patients - In asymptomatic individuals or in patients at low risk of having coronary heart disease, there is little evidence that performing electrocardiograms (ECG) improves health outcomes. In fact, on many occasions, the test will be falsely positive which leads to misdiagnosis, unnecessary invasive procedures, and over-treatment.

Using trade name statins for lowering cholesterol - Statins are the most commonly prescribed cholesterol lowering medications. Because of patents held by drug manufacturers, a few years ago, only trade name (Lipitor, Crestor, etc.) were available. Today, there are a number of cheaper generic alternatives. Generics are equally effective in decreasing mortality, heart attacks, and strokes, as long as the medication brings the LDL-cholesterol into the desired range. A switch to a more expensive brand name statin should be considered only if generic statin causes a side effect or does not achieve LDL-cholesterol goals.

DEXA screening for osteoporosis - The dual-energy x-ray absorptiometry (DEXA) scan is the most commonly performed test to assess for osteoporosis. In women under age 65 or in men under 70 with no risk factors, DEXA screening has not been found to improve health outcomes. If certain risk factors are present, such as having a fracture after the age of 50, taking corticosteroids (e.g. prednisone) for a prolonged period, eating a diet deficient in calcium or vitamin D, smoking cigarettes, or drinking alcohol excessively, DEXA screening is more likely to provide information that will have a positive impact on the patient's health.

Antibiotics for minor sinusitis. Most maxillary sinusitis in the outpatient setting is caused by a viral infection that will resolve on its own. Nevertheless, antibiotics are prescribed in over 80% of doctor visits for acute sinusitis. Antibiotics are required only if symptoms last more than 7 days or if
symptoms worsen after initial improvement.

Pap smears in certain groups of women. There is little argument that regular screening of appropriate women with the Pap test has reduced deaths from cervical cancer. Women younger than age 21 or over the age of 60 who have had a hysterectomy for benign disease, however, do not appear to benefit from this screening. The most commonly detected abnormality in adolescents is cervical dysplasia that typically goes away on its own. Testing in these women usually just leads to anxiety, further unnecessary testing and additional expense. Based on solid evidence, older women who have had a total hysterectomy for a noncancerous problem such as fibroids, no longer need Pap smears.

In most instances, doctors perform these tests, procedures, and treatments with the intention to improve the health of their patients. Unfortunately, statistics do bear out the health benefits of their good intentions. Time will tell, but many other tests or procedures, such as coronary calcium scans, thyroid testing in asymptomatic patients, and vertebroplasty for collapsed vertebrae may also fall into the category of "unnecessary practices". The problem, however, doesn't just lie with doctors. Consumers, too, often encourage these needless and expensive practices. Consider the parent who insists that their star athlete receive a MRI for a relatively minor knee injury in order to get "back in the game". Or patients who insist on receiving antibiotics for a cold because it might turn into something "worse". We all need to be aware of the problem that unnecessary practices can have not only on our pocketbooks, but also on the quality of medical care.

Thursday, January 19, 2012

The Warm Winter Wardrobe

For a variety of reasons, people spend time outdoors in the winter. Exercising, shoveling snow off sidewalks, or just getting to work or the grocery all expose our relatively poorly insulated bodies to the cold. This is where wearing the right clothing can make the difference between being protected and comfortable or vulnerable and miserable. The following common sayings related to dressing for the cold may not be completely accurate, but all contain a valuable message.

"If your feet get cold, put on a hat"

The notion that the body loses more heat from the head and neck has been somewhat dispelled. Studies have shown that the rate of heat loss is essentially the same for any exposed area of the body. Since the area of the head makes up approximately 10 percent of body surface area, heat loss through the head while at rest accounts for only 7-10 percent of total heat dissipation. The amount of heat loss from the head, however, does increase temporarily when initiating exercise due to increased blood flow to the brain. In someone shivering with hypothermia, the percentage of heat loss through the head and neck can increase dramatically reaching as high as 50%. From this, it could be assumed that as someone is becoming progressively colder, more and more heat loss is occurring from the head and neck. Therefore, covering the head and neck makes sense in order to prevent heat loss. Usually this means wearing a hat and scarf. Wearing a hood or balaclava (facemask) also helps to prevent heat loss. Conversely, should you begin to overheat, take off your hat or scarf to vent quickly.

"Cotton kills"

While the saying is somewhat of an exaggeration, cotton clothing ranks at the bottom of the list of appropriate fabrics for cold weather use. With outdoor activity, perspiration is absorbed into any cotton clothing touching or near the skin. As the air pockets in the fabric fill up with water, it ceases to provide insulation. A damp layer of clothing against the skin pulls heat away from the body and can rapidly lower body temperature. Furthermore, when it becomes wet, cotton clothing takes much longer to dry than comparably weighted synthetic fabrics. Garments labeled as corduroy, denim, flannel, or duck are mostly, or entirely, made from cotton. Clothing made from synthetic fabrics or wool are more appropriate and functional for winter wear.

"Dress in layers"

Instead of wearing a single heavy garment, there are several advantages to dressing in layers. This is particularly true during physical activity. The basic idea is that warm air is "trapped" between the layers providing more warmth to the body. Other advantages include wearing special layers designed to keep the skin dry, to provide insulation, and to protect us from wind and rain. Synthetic fabrics, such as Capilene, and Coolmax work best as base layers, worn against the skin. These fabrics keep the skin dry by "wicking" moisture away. A middle, insulating layer of wool, synthetic fleece, or Thinsulate works by trapping air to keep you warm. Goose down is also a great insulator, but it loses almost all of its insulating properties should it become wet. The outer shell layer should be both windproof and waterproof. Ideally, this garment also "breathes" to allow moisture to escape from the body. Gore-Tex and Entrant are trade names of fabrics with these characteristics. Using layers of clothing also allows you to control your temperature more effectively. Should you become overheated or begin to sweat during activity or exercise, you can remove or open up a layer to ventilate. As you cool down, zip up or add a layer.

"Mittens are warmer than gloves"

To a large degree, the warmth of mittens or gloves depends on the insulating properties and thickness of the materials used in their construction. All things being equal, however, mittens are warmer than gloves because the extra air inside creates added insulation, and because fingers maintain their warmth better when they are touching. "Dressing in layers" can apply to the hands also. For example, a thin glove liner beneath a mid-weight glove or mitten can be warmer than a single heavy glove. Be sure that your gloves are not too tight – constricting circulation can lead to cold hands. If exerting yourself in cold, wet conditions, consider carrying a spare pair of gloves or mittens in the inside pocket of your jacket. This gives you a warm, dry set of hand wear to put on should your fingers become cold.

An old Norwegian saying sums it up: "there is no such thing as bad weather, just bad clothing". Wintertime can be a wonderful time to get outside, but not if your clothing is not up to the task. A little preparation and the right combination of clothing can make all the difference in your winter outdoor enjoyment.

Friday, January 13, 2012

Alternatives to Hysterectomy

Each year, in the United States, over a half million women undergo removal of the uterus (hysterectomy). Along with removal of the uterus, the ovaries and fallopian tubes are usually taken also. While this procedure may relieve troubling symptoms, loss of these important organs can have adverse long-term consequences on a woman’s health. Fortunately, a number of less invasive and drastic procedures are available that may be appropriate as an alternative to hysterectomy.

The major, non-cancer related reasons for performing a hysterectomy are uterine fibroids, uterine prolapse, severe uterine bleeding, and endometriosis. In each of these conditions there are treatments that should be considered prior to resorting to hysterectomy, though this may not be the case with cancer involving the pelvic organs. With cancer of the uterus or ovaries, hysterectomy may be the most reasonable treatment option.

Uterine fibroids - These benign uterine growths, also known as leiomyomas, are the most common reason for a hysterectomy. There is essentially no risk of these tumors becoming malignant. As long as fibroids are not causing symptoms, it is reasonable to just monitor their status. Treatment is considered when fibroids become excessively large, cause heavy bleeding, or produce pelvic pressure and pain. If a woman with fibroids is approaching menopause, it is reasonable to wait on treatment since they typically shrink in size and become less symptomatic during this period of life. This is also the rationale behind use of a hormonal treatment using medications known as GnRH agonists that block the effect of estrogen on the fibroids. The downside of this "chemical" treatment is that women usually develop some of the symptoms of menopause.

Uterine artery embolization (also known as uterine fibroid embolization) is a non-surgical procedure in which small particles are injected into the arteries feeding the fibroid. This cuts off the fibroid’s blood supply and causes it to die. This procedure is typically performed by an interventional radiologist instead of a surgeon, and is successful in a high percentage of cases.

Myomectomy is a less invasive surgical option for uterine fibroids than a hysterectomy. This procedure involves the surgical removal of the fibroids alone. Depending on the size and location of the fibroids, it can be done through an abdominal incision, laparoscopically (entering through smaller abdominal incisions), or via hysteroscopy (inserting a thin, telescope-like instrument through the vagina. Myomectomy may be the best treatment option for a woman who is still interested in having children, particularly if the fibroids are interfering with fertility. Unlike hysterectomy, none of these treatments represents a permanent "cure" for uterine fibroids since new fibroids could develop.

Uterine prolapse occurs when the uterus drops from its normal position because of loosening of its supporting muscles. One of the most common causes for this is vaginal childbirth. In milder forms, the use of pelvic floor strengthening (Kegel) exercises or, in postmenopausal women, hormone replacement therapy may help. When more severe, a pessary, which is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix) can be used to help hold it in place. Uterine suspension is a surgical procedure that involves putting the uterus back into its normal position by reattaching pelvic ligaments or by a special material that serves as a sling to support the uterus in its proper position.

Menorrhagia, or heavy vaginal bleeding, can develop for a number of reasons including fibroids, endometrial polyps, hormonal changes, infection, and cancer. Treatment is usually directed at the specific cause, but often, this is never determined. In these instances, treatment options include dilatation and curettage (D&C), in which the lining of the uterus (endometrium) is removed, and medications such as birth control pills, GnRH agonists, and non-steroidal anti-inflammatory medications. With persistent menorrhagia, a procedure known as "endometrial ablation" can be considered. Endometrial ablation is a procedure that destroys (ablates) the uterine lining. It is a minimally invasive procedure performed by inserting an instrument through the cervix and into the uterine cavity. A number of methods including use of a laser, electricity, freezing, heating, or microwave energy can perform the ablation. In most cases, this is an outpatient procedure with minimal recovery time. Endometrial ablation is not recommended for women who wish to become pregnant in the future or who are past menopause.

Endometriosis develops when tissue that behaves like the lining of the uterus (endometrium) grows in other areas of the abdominal cavity, such as the ovaries, fallopian tubes, or outer surface of the uterus. Symptoms of endometriosis include pelvic pain, painful intercourse, spotting between periods, and infertility. Initial treatment of endometriosis usually involves taking over-the-counter or prescription pain medications, oral contraceptives, or hormonal medications that reduce estrogen levels. If medical treatment is unsuccessful, surgery may be required, but in most instances does not require removal of the uterus. Laparoscopic surgery to remove the endometrial growths or burn them away may be all that is required. In more severe cases, an open surgical procedure may be necessary to completely remove the endometrial implants, leaving the uterus and ovaries intact.

In no other part of the world is hysterectomy performed as often as in the United States. Because of the potential for long-term consequences, women should be aware of the alternatives to a procedure that can be life saving, but can also be avoided in many instances.

Friday, January 6, 2012

Different drugs, similar names

What if you were accidently prescribed Lamisil instead of Lamictal? Or Losec instead of Lasix? Would you notice the prescription error? According to the U.S. Pharmacopeia's (USP) eighth annual national report, more than 1,500 commonly used drugs are involved in errors linked to drug names that "look alike or sound alike" (LASA). In fact, each of the top 10 most prescribed drugs in America can be confused with at least one other drug.

The result of this can be serious. Recently, the U.S. Food and Drug Administration released a warning regarding a mix-up involving two medications that led to a serious eye injury. A patient was given a wart removal medication, Durasal, instead of the steroid eyedrop, Durezol. Each year, LASA drug errors harm an estimated 1.5 million patients in the United States, including errors that have caused or contributed to patient deaths.

The examples given in the first paragraph involved trade name medications with similar sounding names, but generic medications can be confused also. For example, the generic antihypertensive medication clonidine (Trade name Catapres) is sometimes confused with the tranquilizer clonazepam (Trade name Klonopin). Taking the wrong one could result in someone with hypertension being inadequately controlled (but very relaxed), or someone for whom a tranquilizer was prescribed having abnormally low blood pressure. With increased prescribing of generic drugs, these types of error are likely to occur more often.

Drugs with similar names can also be confused when prescribing orders are handwritten. Poor penmanship could easily result in prescribing errors involving the medications Celebrex (an anti-inflammatory), Cerebryx (a seizure medication), and Celexa (an anti-depressant). Making matters worse, when the dosages of medications are similar, such as with metformin (a diabetes medicine) and metronidazole (a medication used to treat infections), the person dispensing the medication loses an important clue distinguishing between medications.

How professionals are dealing with this problem. Increasingly, doctors are using computerized record systems that generate printed prescriptions. When prescriptions are delivered by telephone, Pharmacists and technicians may ask to verify drug names and dosages. A system called "Tall Man lettering" that uses a combination of upper- and lower-case letters has been advocated as an additional way to prevent errors. With that system, the LASA medications, prednisone and prednisolone, would be written as predniSONE" and "prednisoLONE". Doctors have also been encouraged to avoid using abbreviations of drug names and to make sure that the "indication”, or reason that the drug is being prescribed, is included. On the governmental level, the FDA screens proprietary names as part of the drug approval process to avoid any confusion with products already on the market. This would not affect, however, those drugs or supplements that are not FDA approved.

What you can do to avoid LASA medication errors:
  • Assume that any prescription could involve a LASA error and be sure the drug in
    hand is the same as the one on the prescription.
  • Check the reason that a drug has been prescribed on the bottle's label or ask the
    pharmacist for this information.
  • With any new medication, undergo counseling from the pharmacist to learn more about
    the medication, its proper use and side effects.
  • Don't store LASA drugs near each other. Place them on a different shelf or location.
  • Dispose of all expired medications and medications no longer needed to decrease
    the risk of confusing it with a recently prescribed medication.
The Institute of Medicine has developed a list of hundreds of LASA drugs. Go
here to see if your medication can be confused with another.