Author Archives: Jeff

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Is Aspirin A Wonder Drug?

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Is Aspirin A Wonder Drug?

Source: Harvard Health Blog

Posted December 22, 2016, 9:30 am
Robert H. Shmerling, MD, Faculty Editor, Harvard Health Publication

 

Imagine that after years of painstaking research, scientists announced the development of a breakthrough treatment that costs pennies a pill, saves lives, and could reduce healthcare spending by nearly $700 billion in the coming years. And you wouldn’t even need a prescription to get it. Perhaps this all sounds too good to be true. But, according to a new study, we already have such a drug: it’s called aspirin.

 

An Analysis Of Aspirin Use

Based on current recommendations, only about 40% of people who should be taking aspirin are doing so. In this new report, researchers asked: what might happen to population health, longevity, and healthcare costs if aspirin use were more widespread? To answer this, they analyzed reams of health data from thousands of patients and estimated the impact of more widespread aspirin use on their health and survival.

Their findings were striking. For people in the U.S. ages 51 to 79, routine aspirin use could, over a 20-year period:

    •    prevent 11 cases of heart disease for every 1,000 persons
    •    prevent four cases of cancer for every 1,000 persons
    •    lengthen national life expectancy by about four months, allowing an extra 900,000 people to be alive in 2036
    •    save $692 billion

 

Is There A Downside To Aspirin?

As is true for all medications, aspirin has its downsides. Among other side effects, allergic reactions may occur. And, aspirin is a blood thinner and can irritate the stomach. Episodes of bleeding and stomach ulcers can be serious. So, the researchers took these into account; the estimates above include these side effects of taking aspirin.

It’s important to emphasize that this study assessed the impact of low-dose aspirin, such as the 85 mg daily dose often found in baby aspirin; higher doses may be recommended for other conditions (and come with added risk). In addition, aspirin can interact with other medications.

For example, if you take low-dose aspirin for your heart and ibuprofen for arthritis, it’s important that the ibuprofen be taken at least 30 minutes after or more than eight hours before the aspirin; otherwise, the benefit of the aspirin may be lost.

 

Who Should Take Aspirin?

For those at highest risk of future cardiovascular problems, including those who have had a prior heart attack or stroke, aspirin is routinely recommended to reduce recurrence.

For everyone else, recommendations vary. Some experts recommend low-dose aspirin for everyone over age 50. Other guidelines make a more conservative recommendation based on age (e.g., 50–79 years old) and cardiovascular risk factors that predict a heart attack or stroke occurring in the next 10 years. Well-studied risk calculators, such as the one developed by the Framingham Heart Study, are available to estimate 10-year risk.

In addition, aspirin is routinely recommended to lower cancer risk in people with certain genetic conditions, including hereditary nonpolyposis colorectal cancer.

 

Why Don’t More People Take Aspirin?

It’s not entirely clear why many people forego aspirin use. My guess is that it’s a combination of factors, including:

    •    a lack of awareness that aspirin is recommended
    •    it wasn’t specifically recommended by their doctor
    •    a greater concern about side effects from aspirin than its potential benefits
    •    a previous bad experience with aspirin use, such as an allergic reaction
    •    an aversion to medications in general

It’s worth emphasizing that when it comes to any treatment — and especially preventive treatments — individual preferences matter a lot. As a result, many reasonable people who would be good candidates to benefit from aspirin will choose not to take it.

 

What Does This Mean For You?

For all the effort to identify new and better drugs, it’s remarkable that we aren’t taking full advantage of what we already have. This new study suggests that large health benefits are not being realized simply because not enough people are taking aspirin.

But each person has his or her own set of circumstances that can affect the both the risks and the benefits of aspirin treatment, as well as his or her own preferences. The decision to take or forego aspirin is a big one — so add this to your list of things to discuss at your next appointment with your doctor.


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Keeping The Human Connection In Medicine

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Keeping The Human Connection In Medicine

Source: Harvard Health Blog

Posted December 12, 2016, 9:30 am
John Sanford Limouze, MD, Contributor

 

Last month, the New England Journal of Medicine published a thoughtful essay by David Rosenthal and Abraham Verghese on the many changes in how doctors are trained and how they practice medicine. Efforts to improve efficiency and accuracy — including the introduction of electronic medical records — offer benefits, and pose some complicated problems.

 

 


Doctors Need To Learn And Do More, More Than Ever

The health care system strives to deliver better care while keeping costs down. Advances in medical science and technology mean there is ever more information for a doctor to know, and policies to curb waste have limited the amount of time we have to learn it all.

Monique Tello wrote about this issue last month; it’s why your doctor is always at the computer. But more than that, these competing goals have had real consequences for how doctors work, how we think, how we relate to our patients and colleagues, and how we feel about our profession.

An example: I’m a hospitalist. It’s a relatively new field in medicine, a product of exactly these forces. Two decades ago, when patients were hospitalized, their primary care doctors would see them in the hospital, in the morning, before returning to clinic for the day. Residents or nurses, often without immediate supervision, managed minute-to-minute affairs. But the culture and standards of practice have changed.

We’ve decided that it’s better to have fully-trained doctors in the hospital all day. In an emergency, I can be at the bedside in an instant. Residents and nurses get more active supervision. Primary care doctors, who have seen their reimbursements cut, can spend more time seeing patients.

But there are downsides. The people I see in the hospital often don’t know me, and I don’t know them. And when a person leaves the hospital, his doctor may not know what I’ve done and why. So, we’ve replaced one set of challenges with another: making sure that there’s good communication between hospitals and clinics.


Electronic Medical Records Can Make That Communication Easier

When a patient comes to me in the hospital, I have immediate access to their entire chart. I can see records from every clinic visit, lab test, x-ray or CT scan, a list of all their possible diagnoses and the medications prescribed to treat them. It’s useful to look at this information before I meet someone new.

After all, if you’re sick and uncomfortable, you don’t want to have to repeat the same story to every new doctor you see. And it’s reassuring to know that the doctor you’re meeting for the first time has taken the time and effort to get to know the particulars of your situation. What’s more, those records make my job easier. My patients may not remember the names and doses of all of their medications. No problem, I can look it all up.


But The Things That Make Us More Efficient May Challenge The Ability To Develop And Maintain Personal Connections

But something valuable gets lost. Maybe there’s a reason a patient can’t remember the names of her medications. Sometimes digging a little bit further can turn up a clue that there’s something more going on. But those clues come up in face-to-face conversations, and over time, not with a glance at a computer screen.

Dr. Jerome Groopman describes another challenge in his book How Doctors Think. Seeing what other doctors have written about a patient can trap us into thinking about their illness in the same way, and blind us to alternative diagnoses. Sometimes the best way to work is to start fresh, and to let your patient tell her story from the beginning.


And Then There’s The Problem Of Distance

We have more and more tests that promise more accurate diagnoses, but require time to coordinate and review. Computerized notes and emails make it easy for doctors to communicate with each other, but have replaced conversations between colleagues. As doctors are increasingly isolated from both patients and each other, they have become demoralized and burned out.


At Its Best, Being A Doctor Is An Extraordinary And Intimate Privilege

We build relationships with our patients and see them through times of both joy and suffering; our relationships with each other help us through the same. It’s hard to do that in a way that’s truly satisfying when we spend most of the day at the computer screen.

Rosenthal and Verghese don’t see an easy fix for these problems. They are largely structural and built into the practice of medicine. But they charge us to remember that the meaning of medicine is in its human connections. Whatever comes next, both doctors and patients should fight to hold on to that.


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Exercises For The Bedridden

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Exercises For The Bedridden

Source: healthresource4u

By Krisxi

 

If you look at the current situation of patients in hospitals nowadays, you will be surprised to see that the number of bedridden patients is increasing. You can also notice that those who are taken at home for palliative care are mostly bedridden individuals, too. There are many reasons why they end up being like this: some have debilitating disease such as multiple sclerosis or fibromyalgia, others have encountered a vehicular accident, while some patients have reached the worst case—being in a coma.

Limited Mobility Bedridden: How Can You Perform Exercises?

 

Since bedridden patients have very limited mobility, it is highly encouraged that they perform even only range of motion (ROM) exercises. Even for a short duration, if performed regularly (like three times a day, for example), it greatly reduces the possibility of these people getting contractures or bed sores.
Contractures are painful in nature, and it doubles the burden a bedridden patient carries. They may make it difficult for especially for the elderly to even turn to the other side of the bed.
A bed sore, on the other hand, often occurs in bony prominences such as the sacral part (the bony part just above the buttocks) or the heel, and it predisposes patients to infection due to an open wound. It may start out as a reddened area, but it can go worse and proceed to a deep, painful ulceration.

Another complication that bedridden patients might get is atrophy of muscles. This takes place when the muscle group is left unused, therefore, shortening and weakening occur. A mobile person prevents this from happening through walking, jogging, and running in treadmill; even simple activities such as lifting a glass of water or cleaning windows will prevent the occurrence of muscle atrophy. But these easy activities are far from easy to be performed by people who are bedridden.


Perform Exercises for Bedridden Clients

These highlight the importance of bedridden individuals’ maintaining mobility amidst of being in bed for very long periods of time. Here are some exercises you can safely do to prevent complications of being bedridden.


 

Palm Stretch

When beginning your exercise regimen, you can start with the most distal extremity. It is also good to start with small parts of the body since it helps build your tolerance to mobility little by little. You can practice first with your hand, since this is the most accessible part of the most bedridden patient.

  1. Bring your entire hand in a first for a couple of seconds.
  2. Open your palm, and stretch your fingers freely for five seconds.
  3. Touch each finger to your thumb.
  4. Repeat the same process on the opposite hand.

palm-stretches

You can do this simple exercise for a couple of times on each hand, but numerous repetitions should not be considered as critical. As long as you are able to move the joints between your fingers and your hands, then, you will do fine. This will prevent stiffness in your joints and also exercise the little muscles you have in your fingers. A reminder though: remember to ask for help if you are too weak to perform it. A caregiver or a loved one can assist you as you please.



Simple Lifts

It does not take a long time before a group of muscle weakens, and performing muscle-strengthening exercises even while on bed can arrest the occurrence. For patients who are recovering, extremity lifts can be done independently. However, there are some who cannot still perform exercises on their own. Like the previous exercise, the family or caregivers can assist them on this, thus, lessening the effort and paving the way to an eventual regaining of health.

For arm lifts, you can do the following:

  1. Begin with your dominant hand. Lift your arm as high as you can. If this becomes too difficult for you, you can settle with resting your upper arm on the bed and lifting your elbow instead until it creates a 90-degree angle.
  2. Hold up your arm for 10 seconds. You can extend for 30 seconds if you do not feel any pain going beyond 10 seconds.
  3. Repeat the exercise on the other arm.

simple-lifts

 


For leg lifts, follow these steps:

  1. Bring both of your legs flat on bet together.
  2. Start with your left leg. Slightly lift it up, maintaining it in a straight alignment.
  3. Bring it to your hip joint slowly. Hold it on that lift for 10 to 20 seconds.
  4. Return the leg to its original position. Repeat on the opposite leg.

 

Side Rolls

Pressure ulcers or bed sores are the main complication each bedridden individual should try to avoid. Similar to contractures, this damage is irreversible. But unlike contractures, this brings much more deformity because of deep wounds. Primary prevention of bed sores is frequent turning, like side-rolling, with two hours being the maximum interval between turns. Bedridden individuals can be turned every 15 or 30 minutes. The more frequent, the better; but it pays to make sure that the patient’s comfort is not compromised.

Steps how to do side-rolling:

  1.  Start on your back. Turn to your right and maintain that position for 30 minutes. You can ask a family member to position your limbs for comfort.
  2. Get back on your back again. Maintain the position for 20 minutes to 30 minutes.
  3. Turn to your left. Stay in this position for another 30 minutes.
  4. Repeat process throughout the day to reduce pressure on bony prominences and as to halt the occurrence of pressure sores even before they occur.

 

You can maintain on a certain side (e.g. On your right) for longer than 30 minutes but not more than two hours. Make sure, however, that your limbs on that side such as your hands and feet as well as your hips are being mobilized often so as not to concentrate the pressure on these parts.

Strengtheners

Isometric exercises are also good for bedridden patients for these stretches or lengthen the muscles. Aside from being lengthened (such as when you do hamstring stretch), muscle groups also need to be strengthened to prevent atrophy. Some of these strengthening exercises are thigh-squeezers and butt-tighteners.

How to do thigh-squeezers:

  1. Lie on your back, with your legs together.
  2. Put a towel in a lengthwise position between your knees. For variation, you can use a moderately soft, long pillow for this.
  3. Squeeze in the towel or the pillow with the use of your knees and hold it for 10 seconds. Release the squeeze and rest for 10 seconds.

 

thigh-squeezes

 

You can perform this exercise both in the morning and in the evening. You can repeat it for five to ten times. But it is important not to strain yourself.

Butt-tighteners are good for bedridden individuals recovering from hip surgery. According to the American Academy of Orthopedic Surgeons, this type of exercise help patients regains strength of the muscle groups around the hips and the glutes while lowering the risk of blood clots.

Follow these simple steps:

  1. Start by lying on your back with legs slightly apart.
  2. You can begin with your right butt muscle, then, strengthen it. Hold this for 5 seconds. Rest for 10 seconds.
  3. Repeat on your left glute muscle. You can repeat this exercise 10 times.

 

Use of Special Equipment’s for Exercise

 

Since astronauts need a lot of exercise in the space to counteract with the absence of gravity, specialized equipment for them have been devised. A good thing, however, is that these equipment’s have been made available also for bedridden patients.
One example is the vertical treadmill that lets an individual to climb up a wall, but with the specialized supports attached to each limb. This requires greater strength of bedridden individuals, thus, ability to exert effort is a main consideration.

Another is fly wheel devices that can be used as a leg press for the bedridden. This effect of fly wheels has been commended by the Human Performance Laboratory at Indiana.

Exercise: Not Only for the Body, But Also for the Mind

 

Performing these exercises can greatly affect the independence level as bedridden patients recuperate with their conditions. Not only that they are spared from acquiring bed sores by being a little more mobile in their beds, but also they get to exercise their muscles, therefore, preventing its gradual decay.

They have to remember, though, that their ability to perform these exercises highly depend on their energy level. So strenuous exercises for the bedridden can be done at their peak energy levels, while those that require minimal efforts can be performed through the day repeatedly. It is important as well that they should stop exercising before they get tired to conserve some energy.

 


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We Really Do Get A Little More Santa-Like, Physically, During The Holidays

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We Really Do Get A Little More Santa-Like, Physically, During The Holidays

Source: The Salt

Originally posted September 21, 20165:12 PM ET – Author: Angus Chen

We Really Do Get A Little More Santa-Like, Physically, During The Holidays
All that holiday grubbing really does pack on the pounds. How much? Researchers tracked the weights of 3,000 people in Germany, Japan and the U.S. and found a weight spike after every major holiday.
Peter Dazeley/Getty Images

 

The holidays on the horizon promise golden opportunities to shamelessly stuff your face. But munch carefully: All that grub comes at a cost.
Researchers averaged the daily weights of 3,000 people in Germany, Japan and the U.S. for a year and saw a spike in weight gain following every major holiday.

In the United States and Germany, people weighed the most at the beginning of January, following Christmas and the New Year. In Japan, people still had experienced a significant gain in weight from December to January, but their highest weights were after the Golden Week, three consecutive holidays that take place the first week of May. Perhaps not surprisingly, there was a sharp gain in the weights of Americans after Thanksgiving, but not among the Japanese or Germans.

That seems to suggest that people really are becoming heavier because of the holidays, and not merely for other reasons — like less exercise during the winter months, says Elina Helander, a post-doctoral research scientist at Tampere University in Finland who worked on the new research, which she and her colleagues share in a letter to the editor in this week’s New England Journal of Medicine.

Prior to this study, she says, “there wasn’t much knowledge around how people’s weights behave around the holidays. There’s really this type of holiday [weight] gain you can see from this data that isn’t because of [other effects].”

Then those panicked New Year’s resolutions appeared to kick in: People in the study started to lose the turkey/candy/beer weight, according to the data. There’s a precipitous drop in weight for all the populations right in the beginning of January, Helander says: “People [might be] motivated to do something. All the fitness centers are full of people in January.” At the end of the one- year study, participants were roughly back to where they started, gaining and losing at most two pounds on average.

The changes in weight the study attributes to holidays is actually petty small, Brooke Bailer, a clinical psychologist at the University of Pennsylvania Center For Weight and Eating Disorders who did not work on the study, points out. “The maximum weight gain is all less than 2 pounds. The United States is 1.3 and Japan is 1.1 pounds,” she says. That might not be enough to tell everyone not to enjoy the Christmas goose.

But it’s also not nothing, says Diana Thomas, a mathematician at the United States Military Academy who studies obesity and was not involved with the study. In a back-of-the-envelope calculation, Thomas says she looked at how much people would need to eat in December to get that rise in weight over the winter. “That would be about a 600 calorie increase per day for the Germans. That’s three extra donuts per day. For Americans, it’s two extra donuts per day. 1 extra donut for the Japanese above and beyond what you’re normally eating.”

The study does show that the weight gain is temporary on average, but that might not be true for everybody. Thomas says it’s difficult for people who are already overweight or obese to lose extra pounds. “We’ve shown it’s very, very difficult to exercise it off, for everybody. Losing weight is rough,” Thomas says. And she’s also found that when people do shed the pounds from overeating, they aren’t losing the same types of body weight equally. “You see a decrease back to the previous weight, but more of it was retained as fat.”

In Helander’s study, all of the participants already had scales to weigh themselves, too. That makes them different from people in the general population who don’t own scales or see their weights every day, says Bailer. “The act of weighing may have influenced their weight loss after all these small weight gains,” she says. People who don’t bother standing on a scale every day might not be as motivated to hit the gym after New Years’.

Still, showing that holidays really are fattening people up is useful. “These spikes tell us that we should view these holidays a little differently,” Thomas says. “And it gives you an opportunity where you can see weight gain and where it happens.” That means you might be able to prevent people from gaining the weight in the first place.


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How to Add Senior Living Conversations to the Table This Holiday Season

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How to Add Senior Living Conversations to the Table This Holiday Season

Posted on November 21, 2016 by Robyn Tellefsen

Source: Our Parents

How to Add Senior Living Conversations to the Table This Holiday SeasonAs families prepare for Thanksgiving, Christmas, and Hanukkah, they’re not just cooking food and decorating their homes—they’re scheduling time to spend together. With everyone present and accounted for, families may use some of their time to talk about senior living options. How can families ensure the experience is positive for everyone involved?
Carla Sutter, director of operations for the SYNERGY HomeCare franchise system, which maintains services in Broadview Heights, Ohio; Madison Heights, Michigan; and Rochester, Michigan (among others) and author of “Where Do We Begin? A Guide to Elder Caregiving,” shares her insight into these critical conversations.

Your Family’s Legacy of Communication

First, it’s important to understand what Sutter calls the “legacy of communication” in your family. Some families have a history of open communication about topics such as health and finances, while others consider these subjects out-of-bounds.
“The legacy of communication helps guide families to know what types of expectations have been set,” says Sutter, who is also a certified advanced social work case manager. “It doesn’t mean you have to follow the same pattern, but accept that if you go outside the pattern, there will be resistance.”
If your family’s communication is more private, and you’ve never broached subjects like your parents’ retirement funds or their end-of-life wishes, you’ll need to carefully consider your timing before diving in.

Timing Is Everything

Though the holidays may seem like an ideal time to tackle these crucial conversations, Sutter recommends families proceed with caution.
“You don’t want to be seen as hijacking the turkey dinner,” she says.
That’s particularly true if you live far away, you haven’t seen each other since last year’s festivities, and you have a limited amount of time to visit. If you only have one or two days to spend together, don’t expect to make all the senior living decisions right then and there, says Sutter. Instead, make it more of an “assessment” visit than a “decision” visit.
“The holidays are a great time to start conversations,” she says. “You’re opening a gift but not putting it all together yet.”

Holiday Conversation Tips

Sutter offers several guidelines to help families engage in healthy conversations about senior living options this holiday season.

Take the Indirect Route

To get senior living conversations started, Sutter recommends bringing up stories of a neighbor or friend to see how your parents react to different scenarios. That way, you’ll have a sense of where they’re coming from and how they feel about various issues. Try not to ask direct questions so they won’t become defensive.

Ask About Their Goals

Sutter shares a story of an older man with two goals: to stay in his house and to care for his wife who had advanced Alzheimer’s. In the meantime, he was busy performing labor-intensive activities such as yard work and snow removal to keep the house operational. Sutter asked, “Can you tell me how some of those tasks you’re doing are ensuring your goals can be maintained?” The gentleman realized if he were to get hurt, his wife would be unable to call 911, and their children lived too far away to intervene. After Sutter echoed his words and goals back to him, he decided to enlist the help of home care a few times a week.

Involve Trusted Advisors

Senior living conversations within families are necessary, but don’t be afraid to invite an outsider to join the discussion. If there is an important person in your parents’ life—someone who plays a major role in their decision-making—invite him or her to the holiday table and subsequent meetings. Whether your parents connect with their pastor, rabbi, physician, or lawyer, get that person involved in the conversation. “We’re willing to listen differently when it’s an outsider,” says Sutter.

Practice What You Preach

Your parents aren’t the only ones who should have life planning documents in place. Anyone over the age of 18 can have a will, a power of attorney, an advance directive, and more. “The same things we’re asking of them, we have to do ourselves,” says Sutter. “You will have more leverage if you talk about your own experience.”

Be Patient And Realistic

Even though Sutter’s family has a legacy of open communication, she says it still took three years of dialogue to get her parents to remove their scatter rugs, and five years to get her dad to give up driving. “You have to do it in bits and pieces,” she says, calling these conversations a “drip campaign” that involves giving information, putting out hints, understanding your parents’ goals, and offering options.
The holidays can be a wonderful time to not only enjoy the company of family and friends, but also to begin important senior living conversations. With sensitivity and careful planning, it can be a positive experience based on collaboration and mutual respect.


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Online Symptom Checkers: You’ll Still Want To Call A Doctor

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Online Symptom Checkers: You’ll Still Want To Call A Doctor

Source: Harvard Health Blog

Posted November 14, 2016, 9:30 am
Monique Tello, MD, MPH, Contributor

 

Online Symptom Checkers: You’ll Still Want To Call A DoctorDoctors make mistakes. I strongly believe in being open about this, and I have written about my own missed or delayed diagnoses on this and other blogs. But guess what? Research supports what I’ve long suspected: when it comes to making the correct diagnosis, doctors are waaaay better than computers.

A recent study compared the diagnostic accuracy of 234 physicians with 23 different computer programs. The authors gave mystery clinical cases of varying severity and difficulty to doctors, and ran the same cases through various online “symptom-checker” programs. The cases came from The Human Diagnosis Project, which itself is a fascinating entity. This project, also known as Human Dx, is a worldwide open-access medical opinion website. People can submit cases that need to be solved, or they can help solve others’ cases. The intention is both for practical use — like, for doctors who are stumped — or as a study tool.

I visited the website, registered, and perused the cases. Here is a typical case on Human Dx:
A 20-year-old female presents with fever and a sore throat. On questioning she also complains of excessive sleepiness. What are the top three most likely diagnoses?
I wrote down:

    1.    infectious mononucleosis (i.e., mono)
    2.    streptococcal pharyngitis (i.e., strep throat), and
    3.    other viral pharyngitis (i.e., just a virus)

And this is exactly what the doctors and the computer-based symptom-checker programs did with 45 distinct clinical cases, with diagnoses ranging from common to rare, and severity ranging from mildly ill to emergency.

These researchers had previously run the cases through 23 different online symptom-checker programs. These are websites where one can type in their symptoms or answer a series of questions for medical advice, like the one on the Mayo Clinic website or WebMD.

Doctors got the correct answer on the first guess about 72% of the time, as compared with a sad 34% for the computer program. Further, doctors got the correct answer in the top three about 83% of the time, as compared with 51% for the computers. Interestingly, when the physicians were separated by level of training, the interns (in their first year out of medical school) got the correct answer in the top three guesses 89% of the time, far better than their senior colleagues.

Obviously, the doctors weren’t perfect — they had a 28% error rate for the number one most likely diagnosis. But, that’s better than the computer programs’ 66% error rate. What the authors envision are programs that can help physicians to improve their diagnostic accuracy.
Until then, if you have to choose one over the other, which one would you pick?


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Home Health Care

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Home Health Care

Source: Center for Medicare Advocacy

Home Health CareThe Center has been hearing from people unable to access Medicare-covered home health care, or the appropriate amount of care, despite meeting Medicare coverage criteria.  

In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. For example, patients have been told Medicare will only cover one to five hours per week of home health aide services, or only one bath per week, or that they aren’t homebound (because they roam outside due to dementia), or that they must first decline before therapy can commence (or recommence). Consequently, these individuals and their families are struggling with too little care, or no care at all.

Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage.  Regrettably, if recent policies and proposed rules are fully implemented, it appears these access problems will only get worse.

To respond to this crisis, the Center is building a coalition to support a Home Health Access Initiative.  With support from Team Gleason and the John A. Hartford Foundation, this Initiative will oppose inappropriate restrictions on Medicare to open doors to Medicare-covered, necessary home care, but we need your help.  If you or someone you know has experienced home health care access issues, submit the story today.

In addition, it is important for beneficiaries and advocates to know what Medicare home health coverage should be under the law, especially for those with long term, chronic, and debilitating conditions. See our detailed information below.

FOR OTHER INFORMATION, FOLLOW ONE OF THE LINKS BELOW OR SCROLL DOWN THE PAGE.

 

When does Medicare cover home health care?

What services are covered?

What if I attend religious services once a week; am I still considered “homebound” for the purpose of Medicare coverage?

The home health agency told me my aide services would be reduced. My doctor hasn’t given me this information. What are my rights?

A QUICK SCREEN TO AID IN IDENTIFYING COVERABLE CASES

Home health claims are suitable for Medicare coverage, and appeal if they have been denied, if they meet the following criteria:

  1. A physician has signed or will sign a care plan, certifying that the services are medically necessary; the physician must also certify that there has been a face-to-face encounter with the patient’ within 90 days prior to the start of care or within 30 days after the start of care.
  2. The patient is homebound. This criterion is generally met if non-medical absences from home are infrequent and leaving home requires a considerable and taxing effort, which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, etc. Occasional “walks around the block” are allowable. Attendance at an adult day care center or religious services is not an automatic bar to meeting the homebound requirement.
  3. The patient needs skilled nursing care on an intermittent basis (less than 7 days per week but at least once every 60 days) or skilled physical therapy, speech therapy, or continuing occupational therapy.  Daily skilled nursing care is available for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional daily skilled nursing is finite and predictable).
  4. The care must be provided by, or under arrangements with, a Medicare-certified provider.

 

COVERABLE HOME HEALTH SERVICES

If the triggering conditions above are met, the beneficiary is entitled to Medicare coverage for home health services. There is no coinsurance or deductible. Home health services include:

  • Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
  • Physical, occupational, or speech therapy;
  • Medical social services;
  • Part-time or intermittent services of a home health aide, and;
  • Durable medical equipment (DME) and medical supplies

ADDITIONAL HINTS:

  1. Medicare coverage should not be denied simply because the patient’s condition is “chronic” or “stable.” “Restorative potential” is not necessary.
  2. Resist arbitrary caps on coverage imposed by the intermediary. For example, do not accept provider or intermediary assertions that aide services in excess of one visit per day are not covered, or that daily nursing visits can never be covered.
  3. There is no legal limit to the duration of the Medicare home health benefit. Medicare coverage is available for medically necessary home care even if it is to extend over a long period of time.
  4. The doctor is the patient’s most important ally. If it appears that Medicare coverage will be denied, ask the doctor to help demonstrate that the criteria above are met. Home care services should not be ended or reduced unless it has been ordered by the doctor.
  5. In order to be able to appeal a Medicare denial, the home health agency must have filed a Medicare claim for the patient’s care. Request, in writing, that the home health agency file a Medicare claim even if the agency insists that Medicare will deny coverage.

SOME IMMEDIATE ADVOCACY STEPS:

1. Review the Medicare home health qualifying criteria in the Center’s Home Health Quick Screen above. If you meet these criteria follow the advocacy steps below.

2. Contact your treating physician, inform him or her of what is happening, and ask for support of the need for the services currently ordered. The treating physician should be the person who decides whether home health services are necessary and whether they should be reduced or terminated.

  • If the physician is able to help, request a written statement explaining the on-going need for the services and that the medical circumstances leading to the doctor’s order for services are still present. Ask the physician not to sign a discharge order for home health services if s/he continues to think the services are medically appropriate.

3. If your home health care will be inappropriately discontinued, follow the steps outlined in the home health expedited appeal Self Help Packet.

4. Request that the home health agency hold a meeting with the patient and family prior to any termination or reduction in services to discuss the appropriateness of the proposed action.

5. If the home health agency has provided poor care or has treated the patient inappropriately, contact your state’s Quality Improvement Organization (BFCC-QIO) (site visited September 24, 2015).

MEDICARE HOME HEALTH PROVISION ENHANCES HOMEBOUND DEFINITION

Sections 501-508 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended 42 U.S.C. ” 1395f(n), 1395(n), 1395fff(b), 1395(x)(v) to modify the Medicare home health benefit. (Public Law 106-554, 12/21/2000.) The provisions discussed below clarified the threshold “homebound” criteria, making clear that individuals who attend adult day care or religious services may also qualify for Medicare home health coverage. These changes became effective upon date of enactment, December 21, 2000.

Homebound Definition

The statutory language clarified and broadened the homebound eligibility criterion in two ways:

Absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound. For many years beneficiaries who attended adult day-care programs were routinely denied home health services.

Absences for the purpose of attending a religious service are deemed to be absences of infrequent or short duration. (Generally a beneficiary whose absences from the home are not considered infrequent or of short duration will not be considered to be homebound.)

The Current Homebound Definition in the Medicare Act reads as follows:

An individual shall be considered to be “confined to his home” if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to an absence of infrequent or short duration. [42 U.S.C. 1395n(a)(2)(F)]

CENTER FOR MEDICARE AND MEDICAID SERVICES CHANGES ITS POLICY FOR DETERMINING HOMEBOUND STATUS.

In a rule that became effective on November 19, 2013, CMS made a significant revision to its homebound policy.  The change reformulates the language from the agency’s old policy into a two-part criteria for determining whether a patient meets the definition of being confined to the home in order to be eligible for the Medicare home health benefit:

1. Criteria-One:

The patient must either:

– Because of illness or injury, need the aid of supportive devices such as

crutches, canes, wheelchairs, and walkers; the use of special transportation; or

the assistance of another person in order to leave their place of residence

OR

– Have a condition such that leaving his or her home is medically

contraindicated.

If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet

two additional requirements defined in Criteria-Two below.

2. Criteria-Two:

– There must exist a normal inability to leave home;

AND

– Leaving home must require a considerable and taxing effort.

We believe that the problem with this new policy is that some patients may be homebound even if they do not require some sort of assistance to leave their residences.  For example, a patient might have severe chronic obstructive pulmonary disease (COPD) that makes it difficult for her to breathe when she exerts herself.  If this patient does not require a supportive device like a cane or walker, special transportation, or assistance of another person, she would be ineligible for the Medicare home health benefit under the new rule because she cannot meet Criteria-One (assuming that leaving home with COPD is not contraindicated).  Under the prior rule, which made the “normal inability to leave home” and “considerable and taxing effort” language the main criteria in defining homebound, the patient’s pulmonary difficulties might have been enough on its own to establish homebound status.

When contesting denials of care or coverage based on homebound status, we encourage beneficiaries and their advocates to utilize the helpful examples of conditions in the policy manual that may indicate that a patient cannot leave the home.  We also believe it could be useful to refer home health agencies and contractors to CMS’ earlier guidance to take a more flexible, fair, and realistic approach to evaluating whether a chronically disabled individual is homebound.

In 2002, the Secretary of the United States Department of Health and Human Services, Tommy Thompson, made changes to the Medicare Home Health Agency Manual and directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria.

In particular, the Medicare Home Health Agency Manual, § 30.1.1, was amended to provide additional, not all inclusive examples of non-medical absences (e.g., family reunion, funeral, graduation) that would not disqualify a person from being considered homebound. The Manual currently includes the following language:

In determining whether the patient has the general ability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case in determining whether skilled nursing services are intermittent) to look at the patient’s condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (meeting both criteria listed above) more frequently during a short period when the patient has multiple medical appointments with health care professionals and medical tests in 1 week. So long as the patient’s overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to home.

This direction from CMS to look at a long view, not a limited snapshot, to determine whether the beneficiary meets the homebound standard is significant. Advocates have long maintained that cases should be reviewed, and qualification for coverage judged, by looking at services provided over the course of a year, not in fragmented 1-2 month segments.

While the additional language does not alter the existing homebound criteria, it provides important direction that the criteria are to be applied flexibly and with a broad view of the patents’ condition. Advocates should use the Secretary’s press release language (see here: http://archive.hhs.gov/news/press/2002pres/20020726d.html  (site visited October 7, 2015) and the manual language to help make these points when clients are erroneously denied coverage.

THE IMPOVEMENT STANDARD AND HOME HEALTH

The Medicare Benefit Policy Manual highlights that any physical, speech, or occupational therapy is a skilled therapy service if the complexity of the service is such that it can only be performed safely and/or effectively under the supervision of a skilled therapist. In order for a therapy to be considered reasonable and necessary, the skilled therapy must be consistent with the severity and nature of the illness or injury as well as the beneficiary’s particular needs. (MBP Manual, Ch. 7, § 40.2.1, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf, site visited September 24, 2015).

The case Jimmo v. Sebelius guarantees in law that homebound skilled nursing or therapy is appropriate for the purposes of maintenance as well as to slow down a patient’s quick decline. Even as CMS said that it never had an “improvement standard,” many Medicare denials continue to be based on the expectation that a patient will not improve. Despite this, the Jimmo case made clear that a patient’s restorative potential is not required by law and homebound skilled nursing and therapy for the purposes of maintenance and slowing a steep declination in health are perfectly acceptable.

  • The Center for Medicare and Medicaid Services’ manual provision that refutes the Improvement Standard can be found here (site visited September 24, 2015)
  • For more information on Jimmo and the Improvement Standard, see here (site visited September 24, 2015)

The Improvement Standard, however, continues to be used to justify denying homebound nursing and therapy services. Should care be improperly denied, you can access a re-review form here (site visited September 24, 2015). Our website also includes various self-help packets should an appeal become necessary (site visited September 24, 2015).


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Vitamin D supplementation and sun exposure: Can we pick and choose?

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Vitamin D supplementation and sun exposure: Can we pick and choose?

Source: Vitamin D Council

Originally Posted on July 11, 2012 by John Cannell, M

sunDespite the increased risk of non-melanoma skin cancers, the Vitamin D Council recommends moderate sun exposure and 5,000 IU of vitamin D3 on days you do not get sun exposure. We are not alone. Recent studies imply that sun exposure does more than simply make vitamin D and that one cannot fully replace the benefits of sun exposure by simply taking a vitamin D supplement.

Dr. Prue Hart of the University of Western Australia makes these points in a recent paper “Vitamin D supplementation, moderate sun exposure, and control of immune Diseases”.

She contends that sunshine affects the immune system via non-vitamin D mechanisms as well as vitamin D mechanisms by citing both human and animal studies. She argues, “It is possible that moderate sun exposure and vitamin D supplementation may be complementary for maximal control of immune-driven diseases.”

She also points out that over the last two decades vitamin D levels have fallen about twenty percent while the incidence of immune system diseases,  such as multiple sclerosis, type 1 diabetes, and asthma have all increased during that same time period. Dr. Hart cited evidence that vitamin D is crucial to brain functioning and added autism as a vitamin D/sunshine related disease.

She predicts, “Within ten years, we should have a clearer answer from randomized controlled studies as to whether vitamin D per se can reduce the incidence and progression of immune diseases, cardiovascular disease, autism, and more.”

In regards to sun exposure recommendations, Hart stated, “Repeated short sun exposures to a larger body surface area are likely to have a greater effect than longer exposures of smaller areas.”  Of course, few of us are in a situation that allows large surface area exposures every day. However, weekends and holidays offer the opportunity of nearly full body short sun exposures for both adults and children. On the days one gets such exposure, there is no need to take oral vitamin D supplementation.

Ten years is a long time to wait for the randomized controlled trials that many believe will settle the vitamin D issue. During those ten years, it seems wise to protect you and your family with at least some moderate sun exposure combined with adequate daily doses of vitamin D3 on sunless days.


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Chill Out: Stress Can Override Benefits Of Healthful Eating

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Chill Out: Stress Can Override Benefits Of Healthful Eating

Originally posted: September 27, 2016.  Heard on All Things Considered – by Allison Aubrey

Source: The Salt

 

Chill Out: Stress Can Override Benefits Of Healthful EatingEating well has many known benefits. But a good diet may not be able to counteract all the ill effects of stress on our bodies.

A new study, published in Molecular Psychiatry, suggests stress can override the benefits of making better food choices.

To evaluate the interactions between diet and stress, researchers recruited 58 women who completed surveys to assess the kinds of stress they were experiencing. The women also participated in what researchers call a “meal challenge,” where they were each given two different types of meals to eat, on different days.

One meal was high in saturated fat, the type of fat linked to cardiovascular disease. The other meal was high in a plant-based oil, which is considered more healthful.

“When women were not stressed and they got the healthier meal, their inflammatory responses were lower than when they had the high saturated fat meal,” explains study author Janice Kiecolt-Glaser, director of the Institute for Behavioral Medicine Research at the Ohio State University. She says this was not a big surprise.

But here’s the part that may seem counterintuitive: “If a woman was stressed on a day when she got the healthy meal, she looked like she was eating the saturated fat meal in terms of her [inflammation] responses,” Kiecolt-Glaser explained.

In other words, the more healthful meal was no better in terms of its impact on inflammation. “The stress seemed to boost inflammation,” Kiecolt-Glaser explained.

The kinds of stressful events the women experienced weren’t life-threatening. Rather, they’re the sorts of events that make us feel overwhelmed or out of control, such as a child care scramble or caring for an elderly, sick parent.

The researchers measured several markers of inflammation in the body, including C-reactive protein, or CRP.

Over a lifetime, higher inflammation levels are linked to an increased risk of a range of diseases, including “cardiovascular disease, Type 2 diabetes, arthritis, some cancers,” Kiecolt-Glaser explains. “It’s an ugly list of possibilities.”

The findings add to the evidence that stress is a powerful player when it comes to influencing our health. Kiecolt-Glaser’s prior research has shown that people who are stressed heal wounds more slowly. She has also demonstrated that stress can promote weight gain by altering metabolism and slowing down calorie-burning.

Kiecolt-Glaser says there’s still a lot that’s unknown. For instance, in this new study, she’s not sure how the inflammation levels of stressed-out women would have been influenced by an ultra-healthful meal — say, an avocado with greens on a piece of whole-grain toast. She points out that both of the meals the women ate for this study were very high in calories and had about 60 grams of fat.

Now, if you’re looking for the upside in this line of research, rest assured: There are a whole range of strategies that have been shown to help manage stress.

“Close, personal relationships are perhaps the world’s greatest stress reducer,” Kiecolt-Glaser says. Studies have also shown mindfulness meditation and yoga to be effective.

And as we’ve reported, even doing nice things for others can help keep stress in check.

When I was reporting this story, I asked stressed-out Georgetown University law students what they do to manage stress. They pointed to a range of activities — from salsa dancing to listening to hip-hop to going to the gym. “I really enjoy exercising when I’m stressed. It gives you an outlet to distract you,” Marina Smith told me.

And it seems these students are on to some good strategies, says Aric Prather, an assistant professor at the University of California, San Francisco School of Medicine, who studies how lifestyle choices influence health. “Exercise and social connectedness,” he says, “are effective in improving people’s well-being and their ability to cope with stress.”

 


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Is there a way to lower the cost of an EpiPen?

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Is there a way to lower the cost of an EpiPen?

Source: Harvard Health Blog

POSTED OCTOBER 12, 2016, 9:30 AM

Celia Smoak Spell, Contributor

 

EpiPenWhen a person with a life-threatening allergy is exposed to his or her “kryptonite” (be it peanuts, bee stings, latex, or something else) the result is an intense immune response called anaphylaxis. The throat tightens, the tongue swells, blood pressure can crash, and it can become hard, maybe even impossible, to breathe. Rapid treatment is critical. “If a reaction is that severe, epinephrine basically saves a person’s life until she or he can get definitive healthcare,” says Dr. Susan Farrell, emergency room physician and assistant professor at Harvard Medical School.

Epinephrine is cheap — about $5 per milligram. The problem is that for people at risk for anaphylaxis, epinephrine needs to be handy and given quickly when an allergy exposure occurs. That’s the “beauty” of the EpiPen. The device makes it easy to keep an emergency dose available and simple to administer correctly. The dose delivered by the adult EpiPen is an inexpensive 0.3 mg. The medication is not costly; it’s the injector that’s expensive. But the high cost of EpiPens is not news. For a person with a high deductible insurance plan (or no health insurance at all), an EpiPen Two-Pak costs $622.09 at Walgreens. It is not much cheaper at other pharmacies and can still cost as much as $400, even with coupons and insurance combined.

Why are EpiPens so expensive?

A lack of competition is one of the reasons that Mylan, the company that makes EpiPens, can continue to increase the price. A similar product called Auvi-Q was pulled off the market due to concerns that the device did not deliver the right dose of medicine, according to Dr. Ana Broyles, allergist and immunologist at Boston Children’s Hospital. Other alternatives have not been that much more successful. Adrenaclick, for example, is significantly cheaper than the EpiPen ($188 at Walmart’s pharmacy) but Dr. Broyles finds it harder to use. It is rarely prescribed. Other companies have been trying to develop generic (and thus cheaper) versions of the EpiPen, but none have received FDA approval yet.

A proposed solution that won’t actually bring down the cost — and has the potential to influence “independent” recommendations

Most people who need this device don’t buy just one. They have them all over the place — the car, the office or school, a pocket or a purse. That’s why it hit consumers especially hard when they were forced to pay upwards of $500 for two EpiPens. Surprisingly, it was Mylan that proposed a solution to the soaring cost. It recently asked the U.S. Preventive Services Task Force (USPSTF) to place the EpiPen on its list of preventive medical services. That would make it completely covered by all insurances, including the Affordable Care Act and private insurance companies. There would be no co-pay, which sounds great.

But the mission of the USPSTF is to evaluate strategies to maintain health and prevent Epinephrine is not preventive. It is not something you inject before you’ve been exposed to an allergen. It’s not something you take regularly to prevent a reaction. It’s a medication you inject after you’ve had a reaction. So, should the USPSTF make recommendations on EpiPens at all? Just yesterday, an opinion piece in the Annals of Internal Medicine argues that EpiPens are not only not a preventive service but in order for the USPSTF to remain completely unbiased and evidence-based, its recommendations should not determine insurance coverage at all.

Even if EpiPens did land on the list of preventive medical services, it probably wouldn’t benefit consumers in the long run. Mylan could continue to raise prices with little backlash from the public and would have no incentive to keep prices competitive or reasonable. While you wouldn’t be paying for your EpiPen out of pocket, your employer or your insurance company would. And those costs could simply circle back to you in the form of increased premiums or other lost benefits.

With so many children and adults at risk for severe allergic reactions, this discussion is important. Developing generic versions of the same medication and an equivalent delivery device creates competition. Those with allergies need better options, including improved access at lower cost — and transparency.


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