Advocating through Inquiry

Please check out this new post I have written for Athenahealth's Leadership Forum.  It's called "Advocating through Inquiry" and relates some intriguing ideas from Gerald Hickson and his colleagues from Vanderbilt.  St. Francis makes an appearance, too.

Please let me know what you think about it, either here or there.  Thanks.

KHN explains why insurers cancel policies

Kaiser Health News has the best explanation of how and why insurers can cancel policies in the individual health insurance market.  Excerpts:

News that health insurers are ending the policies of what could be millions of Americans has rattled consumers and added to the debate over the health care law.

If you or a family member has been notified that your individual policy is being cancelled at year’s end, you may be stunned and upset.

No one knows how many of the estimated 14 million people who buy their own insurance are getting such notices, but the numbers are substantial. Some insurers report discontinuing 20 percent of their individual business, while other insurers have notified up to 80 percent of policyholders that they will have to change plans. 

Q. Why are premiums changing?
A. Under the old rules, insurers could decide whether to accept you – and how much to charge -- based on answers to dozens of medical questions. You no longer have to fill out those forms. Starting Jan. 1, insurers can no longer charge women more than men, reject people who are sick or charge them more and can charge older people only three times more than younger ones. They’re also adding new benefits.

As they drew up the rates for 2014, insurance firms had to make educated guesses about how many customers would stay, how many new ones they would attract – and what the health conditions of those new members might be.  Actuaries say the new rules on how much insurers may vary rates level the playing field, making premiums more of an average. Older buyers or those who had above-average health problems – and whose former rates reflected those problems – may find their premiums going down. Younger or healthier people, on the other hand, may find premiums going up, sometimes sharply.  Under the new rules, consumers “are not paying based on their own health status, but an average health status,” said Robert Cosway, an actuary with consulting firm Milliman. “The positive side is that people in poor health won’t have to pay as much, but the way you get there is that people in better health have to pay more.”

A word from one of the 5%

The President's spokesperson today tried to explain why the President's statement--"If you like your health plan, you can keep it."--was true.

Listen from minute 3:00.

"As the law says, and as the President made clear . . . if you had insurance coverage on the individual market when the Affordable Care Act was passed into law and you liked that plan and you wanted to stay on it . . . you can keep that coverage. You are grandfathered in . . . in perpetuity."

Here in Massachusetts, I am not allowed to keep the individual plan I have had. I am required to buy a new plan effective March 2014. And, as I have discussed in my two previous posts, that new plan is not the same. I guess the fine point is that I bought my plan after March 2010, when the health care law was enacted.

Maybe this is all a distinction that doesn't make a difference. After all, I like some changes in the plan and don't like some others. But the answer given today doesn't square with many people's perception of the President's promise. As indicated in press reports, like this one from the Los Angeles Times, others of us who are in the 5% covered by individual plans are similarly confused.

For example, quoting the reporter's question, "Can you explain in just really plain and clear terms" how the spokesperson's comments jibe with this report:

Nearly 2 million Californians have individual insurance, and several hundred thousand of them are losing their health plans in a matter of weeks.

Blue Shield of California sent termination letters to 119,000 customers last month whose plans don't meet the new federal requirements. About two-thirds of those people will experience a rate increase from switching to a new health plan, according to the company.

I have been listening to actuaries for many months who made it clear that the new plans would have to be more expensive to cover the law's guaranteed issue and other insurance requirements. Those requirements are extremely desirable in providing insurability and financial security to millions of Americans and are, in fact, key attributes of the ACA. If the costs and benefits of these requirements had been addressed honestly by the administration, perhaps it would not feel the need to parse the President's promise as finely as his spokesperson did today.

Thanks, Professor Ocasio!

I want to thank Willam Ocasio, Kellogg professor of management and operations at Northwestern University, for saving me some money. He read my last post about my family's Blue Cross Blue Shield of MA plan under the Affordable Care Act and suggested that I could save "a lot of money" by choosing the $500/$1000 (individual/family) deductible plan instead of the plan with no deductibles.  It turns out that he is right, but it also turns out that I am still worse off than my current Massachusetts Connector plan. 

This BCBS plan under the ACA is about $350 less per month than the no-deductible plan.  Even if I run through the $1000 in deductibles during the course of the year, I break even after three months. Inexplicably, too, the visit and imaging co-pays are less than they would be in the ACA no-deductible plan.

But now, let's compare the ACA deductible plan to my current Massachusetts BCBS plan:

So, my initial point remains valid. I am still worse off under the Affordable Care Act than I was under the Massachusetts plan. My premium has gone up $220 per month (or 15%), and I will likely spend another $1000 covering the deductibles. My total percentage increase depends on how much additional care I need past my deductibles. Paradoxically, the more I need to use medical services, the smaller my annual percentage increase.

By the way, it is not clear to me how many people will have the time and inclination (and math skills) to compare the 95 plans on the Massachusetts exchange--but I guess I'm pleased that the data are available for all to see . . . including a helpful professor from Illinois!

Didn't they promise lower costs?

Ross Douthat writes in the New York Times that Americans will soon be able to get "a real look at what Obamacare is selling them."

What will they find? One way to understand what is being offered is to think in terms of three “mores.” Insurance à la Obamacare will be more expensive, more subsidized and more comprehensive than what was previously available on the individual market.

Well, proof of the first aspect has landed at my home here in Massachusetts.  Here's a chart comparing the Blue Cross plan I have been able to purchase under the rules of the Massachusetts Connector to the one I will be able to be able to purchase under the rules of the Affordable Care Act.

To summarize, for $600 more per month, my co-pay for almost everything goes up. My share of an inpatient admission or outpatient surgery goes up 233%; a CT or MRI goes up 500%; and ED visits are double the cost.

Now, I do get the benefit of an out-of-pocket maximum of $3000.  But I will pay $7200 extra for that protection. To break even, I would have had to spend $10,200 in out-of-pocket items under the Massachusetts plan.

I know I could downgrade to a lower level of insurance and reduce my monthly premiums, but then other items would also change in price and availability.  This is the plan that best meets our needs.

Douthat noticed the same pattern in his home state of Connecticut. "There the 'more expensive' part of the new regime is readily apparent."  He believes that the higher rates are "because insurance companies now have to take customers with pre-existing conditions, which drives everyone’s rates up. But they also bite because buyers are getting more insurance than the older system’s cheapest plans offered."

Not so here in Massachusetts, where pre-exisiting condition exclusions have been outlawed for years and where--as you see--we are not getting more insurance than the older system.

I think the explanation for this uptick in cost in Massachusetts has to do with the group and individual definitions and rating factors that BCBS has to use under the ACA, so I'm not blaming them.  And actually, their premium plan is less expensive than those offered by other insurers in Massachusetts, so some competition seems to exist.

I'm also happy to pay my fair share.  In particular, I have no problem at all with having my tax money used to help subsidize those who can not afford insurance.

But, jeez, couldn't you have kept my monthly premium rate increase to something less than 40%?

In memoriam: Marilyn Kass

Marilyn Kass, aka Momo, passed away last night after a long battle with breast cancer.  She has been an inspiration to many of us.  The humorous picture above was from a recent adventure in horseback riding.  Here's the message she has had on her blog--subtitled, "Breast cancer--It's amazing what you can get used to."

Thanks for checking out my blog. For those of you dealing with cancer directly or indirectly we’re in it together. This journey has more ups, downs and surprises than a roller coaster. Hang on. Breath. Wherever you are, it’s temporary.  Relish the good times when they come and have faith when the crappy times roll along that they too are only temporary.

Lean on your friends and family. Seek out folks who want to help and let them. It will make them feel good. When you are negotiating for an upgrade or waiting in line, tell the folks across the counter that you have cancer. It just might get you a better seat. Then, forget about it as much as possible. Try to win with the cards you’ve been dealt and bluff if it helps.

Email any time I love hearing from you.
xoxomomo

Pigs in service to America

The NSA probably knows this already, so I think it is all right to spread the word.

I noticed in my blog statistics that someone from the Department of Homeland Security was looking at a series of my favorite Lean training blog posts.  They are about drawing a pig.  Hey they are: Part 1, Part 2, and Part 3.

But I wondered what led them to these sites.  Well, the statistics app suggests that they came to it via a process improvement website from the UK.

However they got here, I am pleased, and I hope they find the exercises useful. I hope someone lets me know someday if the training will be used. And where? At the airports?

World Series Symphonic Battle

A sweet interplay between orchestra members from Boston and St. Louis.  Fun!

Halamka's correct about IS implementation

One of the best decisions I made before taking on the CEO job at BIDMC was to meet with John Halamka to make sure he would be staying on as chief information officer.  Once he said yes, I knew it would be safe to sign on, confident that our clinical and administrative information systems would be best of class.

As you read this blog post by John, you can get a sense of his wisdom and common sense. The closer:

Policies are good.   Policymakers are well meaning.  Timelines are set in such a way that none of these activities - Health Insurance Exchange, ICD-10, Meaningful Use Stage 2, or HIPAA Omnibus Rule have enough time for testing, piloting, and cultural change.

I'm not yet at that time in my life when I resist change or innovation.   I'm simply an IT leader and physician in the trenches who knows that 9 women cannot create a baby in a month.

How to win at chicken

Do you recall the old game of chicken?  Two cars (driven by slightly crazy people) drive towards each other at high speed.  The person who swerves first--to avoid the pending collision--is "chicken" and loses.

If we look at this as a problem in decision analysis, we find the following matrix of possible results.

The question often posed about this game is how you can guarantee that you will win, but also guarantee that you don't end up "winning" by crashing into the other person, who has also "won."

The solution is quite simple.  As you approach the other car, you pull the steering wheel off its column and--making sure the other person sees you do it--you throw it out of the window. The other driver now knows that there is no way for you to veer off, and there is a very high likelihood that s/he will be "the chicken" and turn away.

Many cities and towns and states across the country face a big problem called "Other Post-Employment Benefits."  These benefits are a promise made to public employees that their government entity will pay for their health care insurance after retirement, supplementing Medicare until the day they or their spouse dies.  OPEB represents a huge future liability for local governments, with amounts well in excess of their willingness to pay to build up an appropriate level of reserves.  In my city, for example, the unfunded OPEB amount is about $600 million (equal to two years of the entire city budget.)  About 90,000 people live here, and that amount of money represents an extra mortgage of about $18,000 for each of the 33,000 households in the town. (According to this article, the statewide unfunded obligation  for Massachusetts cities and towns is $26 billion, a mortgage, again of $4000 for every man, woman, and child living in the state.)

The pattern across America is to ignore this problem or apply band-aids.  At best, local administrations put in place a savings fund for new employees or reduce future benefits for this cohort, so they don't add as much to the problem going forward. But there are actually very few new employees.  Meanwhile, the localities have to engage in a pay-as-you-go policy for current retirees.  But they don't plan very well for the fact that even the current retirees are likely to need more and more expensive care over time, draining the municipality as it tries to keep up with the pay-as-you-go plan. More importantly, most have no plan whatsoever to deal with the large number of incumbent employees who will be added to the OPEB rolls as they retire. 

Relatively new accounting standards from the Governmental Accounting Standards Board (GASB) Statement No. 45 provide for the recording of OPEB expense and the liabilities in the financial reports of state and local government employers. But those standards do not require governments to solve the problem.

So, the way most localities are dealing with this problem is by playing chicken and throwing out the steering wheel.  They don't like to say this publicly, but they fully expect that, when the time comes, the federal government will rescue them from this situation.  Indeed, the more localities that choose to play chicken, the more likely this will be the result.  The last thing the US government would want is to have dozens or hundreds or thousands of local government entities going into default.  The political pressure from retirees, local taxpayers, and local governments will come down on Congress to solve the problem. (This possibility is acknowledged in a 2011 Congressional Budget Office study.)

What makes this all so risky and difficult is that it will be occurring precisely when the funding for Medicare--for non-government retirees--also gets very tight because of the country's demographic trends.

A better plan would be to have the federal government impose the kind of standards it does on private companies, requiring localities to fully fund OPEB liabilities.  Give the local governments a period of time to catch up, but don't let them engage in this kind of game of chicken.

Conversation Ready on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Who’s Conversation Ready? How Health Care Can Respect End-of-Life Wishes — will take place on Thursday, October 24, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Kelly McCutcheon Adams, LICSW, Director, Institute for Healthcare Improvement
• Lauge Sokol-Hessner, MD, Attending Physician, Beth Israel Deaconess Medical Center (BIDMC)
• Kate Lally, MD, Medical Director of Palliative Care, Kent Hospital and Medical Director, VNA of Care New England
• Donna Smith, MD, Virginia Mason Hospital

For over a year, building on others’ great work, IHI has been engaged in two groundbreaking initiatives to reduce the confusion and improve the circumstances that surround end-of-life care for most Americans in the US. The Conversation Project, founded in collaboration with IHI, is a grassroots effort to encourage and enable every one of us to discuss our wishes regarding end-of-life care with our friends and loved ones, long before there’s a medical crisis. The second initiative, Conversation Ready, is designed to capture the ways in which health care organizations can effectively respect and respond to these wishes. Ten organizations have been working with IHI to share and refine their best practices, and we’re going to check in on what they’ve learned on the October 24 WIHI: Who’s Conversation Ready? How Health Care Can Respect End-of-Life Wishes.

Three clinical leaders from notable health care systems will be on hand for this WIHI, along with IHI’s Kelly McCutheon Adams. You’ll hear about an effort underway at BIDMC to embed a system of “4 Rs” into all patient engagements: Reaching out to learn a patient’s end-of-life preferences and values, followed by processes to Record and reliably Retrieve and Respect the information. Care New England has a number of innovations underway, including the designation of a “conversation nurse” who ensures that the goals of patients and families stay at the forefront of all end-of-life decision making. At Virginia Mason Medical Center in Seattle, the electronic medical record is becoming an effective home base for important and visible information about preferences regarding end-of-life care.

This is just a taste of what’s ahead on the October 24 WIHI. Host Madge Kaplan and her guests are also eager to find out what’s going on at your organizations. There’s been considerable progress with palliative care in many, many hospitals. But the end-of-life conversation that starts at home among friends and family and then continues straight through to the clinical world, without running into a lot of roadblocks, isn’t yet the norm. That’s what we’re all working on. 

I hope you'll join us! You can enroll for the broadcast here.

Not leaping ahead

It is so striking that hospitals are keen to accept and publicize the results of the fairly meaningless US News and World Report hospital rankings--rankings that have no statistical validity and are based in part on rumors about the quality of care delivered--and yet complain bitterly when the Leapfrog Group posts scores based on data about preventable medical errors and injuries.  The scores revealed “little improvement in safety overall” since the last report.

In American life, the three great lies are (1) "The check is in the mail;" (2) "I'll still respect you in the morning;" and (3) "I'm from the government and I'm here to help you."

In the hospital world, the two great lies are (1) "Your data are flawed" and (2) "Our patients are sicker."

This article, though, contains a new rebuttal approach:

Jeff Dye, president of the New Mexico Hospital Association, fired back at the data, saying many of the state's hospitals have stopped participating in the Leapfrog survey because they “see it as extortion to obtain a higher score.”

Perhaps someone can explain what that actually means.  Heaven forbid that a hospital's score would improve.

A chip off the old block

When your father is Richard Corder, a fellow who spends a lot of his time helping hospitals become more patient-centric, you develop insights somewhat different from other 11-year-old girls.

Richard (hungry and sitting at the kitchen table, just about to bite into a tuna sandwich his wife has thoughtfully prepared):

Ah, this is just what the doctor ordered.

Carrie (sitting across from him):

Shouldn't that be, this is what the patient really wants?

Kicking Concussions

Personal adversity can sometime produce a commitment to change.  Caroline Cohen is a high school student in our town who suffered several concussions in sports activities, the most recently in 2011 during a Memorial Day soccer tournament.  Following that last injury, she was forced to miss school and, eventually, to give up all contact sports.

To help spread the word about concussion awareness, she recently organized a one-day, 3v3 "Kicking Concussions" tournament for U10, U12, and U14 girls in our town.  The proceeds from the tournament were designated to benefit the Boston University Center for the Study of Traumatic Encephalopathy, a research institute where they study chronic traumatic encephalopathy (CTE), degenerative brain disease that results from traumatic head injuries.

Caroline noted, "Through this tournament, I hoped to raise money for advanced research in the field, in addition to educating younger players about concussions."

Supported by her friends (Caroline seen here with her buddy Katie Nugent) and some local merchants who offered prizes, the tournament was publicized widely among the town's girls soccer community.

Well, the day was a great success!  Dozens of girls played dozens of games, and they were able to raise over $1000 for the cause.

Solving two types of IT problems

Sometimes you hear an idea that is perfect.  Here's one from a loyal reader:

My wife suggests switching NSA and HHS personnel -- two birds with one stone.

How marketing works on the web

You have to hand it to the world's spam engines.  This comment came in within hours of my posts about the problems with the health insurance exchange site! (I've taken out the links.)

CMS web design allows businesses to organize and maintain their website content fast and effortlessly. Besides, one can have an unlimited number of pages and a full site-search engine.
Website Design Company Bangalore | Bangalore Web Development Company

The health insurance exchange on 35 floppy disks

We can rely on The Onion to make us laugh out loud, even as we cringe a bit because of the underlying truth.  Here's an excerpt of their version of how the Administration is solving the health insurance exchange problem:

WASHINGTON—Responding to widespread criticism regarding its health care website, the federal government today unveiled its new, improved Obamacare program, which allows Americans to purchase health insurance after installing a software bundle contained on 35 floppy disks. “I have heard the complaints about the existing website, and I can assure you that with this revised system, finding the right health care option for you and your family is as easy as loading 35 floppy disks sequentially into your disk drive and following the onscreen prompts,” President Obama told reporters this morning . . .

Induction Therapy in Kidney Transplantation - Summary

Most kidney transplant centers in the United States utilize induction agents as part of their immunosupression protocols. The reasoning behind is that induction therapy has been shown to reduce the rate of acute rejection, however no trial has yet demonstrated an improvement in long-term graft survival.  Induction therapy has also expanded in centers using steroid-withdrawal protocols and in patients with expected delayed graft function due to prolong ischemia time (ECD/DCD kidneys), since calcineurin inhibitor initiation may be delayed (significant vasoconstriction from CNI may potentially delay recovery).

Rabbit antithymocyte globulin (rATG or Thymoglobulin) is the most common agent used in more than 55% of transplant cases in the USA, despite not being FDA-approved for this use (only for treatment of severe cellular rejection). Curiously, rATG is prepared by immunizing pathogen-free

rabbits with a cell suspension of human thymic tissue (thymocytes). After immunization, the serum is harvested from rabbits and immunoglobulins against thymocytes are isolated and subjected to a number of purification processes. Samples from more than 26,000 immunized rabbits are pooled to achieve a high level of batch-to-batch consistency!

Our center uses ATG for induction in high immunological risk patients and Basiliximab for low risk patients in combination with tacrolimus and MMF for maintenance. Steroid withdrawal is performed on most patients by the end of first week post-transplantation, with the exception of highly sensitized patients.

Below a summary table of the 3 most common induction agents in clinical use today, their target cells, dose, cost and side effects.

Antibody	Brand	Class	Lymphocyte depleting	Antigenic Target and Cells	Typical prescription	Side effects
Basiliximab	Simulect (Novartis)	Monoclonal	No	IL2 receptor (CD25)   Activated T cells	20mg x2 doses  U$4,254	Hypersensitivity reaction (rare)
Rabbit antithymocyte globulin	Thymoglobulin (Genzyme)	Polyclonal	Yes	Multiple Ag   Mainly T cells, to a lesser extent B and NK cells	1.5mg/kg 3-7 doses  U$7,824-18,256 Premedicate with steroids and Tylenol Decrease dose if WBC<3 or="" ptls="" span="">	Fever, chills, dyspnea, nausea, diarrhea, headache, general pain and pulmonary edema (cytokine release syndrome)
Alemtuzumab	Campath 1H (Berlex Laboratories)	Monoclonal	Yes (more prolonged)	CD52 Ag T, B and NK cells, monocytes, macrophages, dendritic cells, eosinophils, mast cells	30mg x1 dose  U$2,065	Generally none when given subcutaneously

More details about the use of induction therapy in transplantation on this prior blog

First rule of governing: Stay on message

There is so much good in the Affordable Care Act, and I am confident it will have lasting value for the country.  There is an undeniable and important need for people to have health insurance and not be subject to arbitrary decisions by insurers about pre-existing conditions, coverage limits, and the like.  And those, after all, are the main features of the law.  But sometimes I wonder if the President has speechwriters who understand about the sound bites the media are likely to pick up-- words that distract people from those attributes of the law.  Here's the portion of his remarks that I heard over and over on the radio after his speech about the computer problems with the health care exchange:

There's no sugarcoating it. The website has been too slow. People have getting stuck during the application process. And I think it's fair to say that nobody's more frustrated by that than I am. Precisely because the product is good, I want the cash registers to work, I want the checkout lines to be smooth, so I want people to be able to get this great product. 

Nobody's more frustrated by that than I am.

With respect, sir, no one is concerned about your frustration. This is a time to show empathy to the thousands of people who have been through the unsuccessful interactions with the federal exchange system. 

I want the cash registers to work.

OMG, what a terrible metaphor! This is not a time to portray health insurance as just another internet product, nor the federal government as an entity solely concerned with taking your money.

Meanwhile, Cheryl Clark, Senior Quality Editor at HealthLeaders Media, noted the tin ear of the bureaucracy on her Facebook page:

In case you missed it, last night embattled healthcare.gov sent this message. Note the "easier than ever" qualifier.

From HHS spokesperson Joanne Peters: "As part of our ongoing efforts to make improvements every day, new content is being featured on HealthCare.gov in response to user feedback. It's now easier than ever to preview plan information, access a downloadable application form and find in-person help in local communities. We're giving users more information to make the decision that's right for them about how to apply and enroll in affordable health coverage."

This was an administration that was so good at messaging during its election campaigns. I really wish they would get better at it while governing. The stakes are very high.

Costs of Care Essay Contest is Back

Neel Shah has been running the Costs of Care essay contest for several years, and it is time to send out the reminder for the fourth annual event.  Here's the website. There will be $4000 in prizes for the best stories from patients, doctors, and nurses illustrating the importance of cost-awareness in healthcare.  The deadline for entries is December 1, 2013.

Neel notes:

Entries should be 500-700 words and should be typed and double-spaced. Students are strongly encouraged to submit. Entries will be judged based on the quality of the writing and the relevance of the anecdote to the topic of cost-awareness in medicine. We are primarily seeking stories. The focus of the contest is not to suggest policy solutions.

The judging panel is again impressive:

Andy Grove, innovator, Time Magazine Man of the Year (1997)

Maureen Bisognano, registered nurse, President of the Institute for Healthcare Improvement
David Goldhill, television executive, author of “Catastrophic Care: How American Health Care Killed My Father–And How We Can Fix It”
Steven Brill, journalist, author of Time Magazine’s “Bitter Pill: Why Medical Bills are Killing Us”

Last year, I posted the winning essay by a patient.  Take a look.

Thanks to Harvard Pilgrim Health Care and the AAMC for sponsoring this event.

Diuretics vs. Ultrafiltration: Isn’t the debate settled yet?

We have all been called in to see patients who have developed AKI after receiving mechanical ultrafiltration (UF) for acute decompensated heart failure (ADHF). In almost all situations I have experienced, UF was started early, perhaps without optimization of diuretic therapy. The UF program at our institution is run by the Cardiology service. In spite of the weight of the current evidence, I have seen a distinct specialty specific bias towards UF (Cardiology), and against UF (Nephrology).

After I received the nth consult for AKI in the above setting, I decided to review some evidence for a cardiologist friend. I thought it’ll make for a review of a pertinent situation that we all will continue to face.

In brief, three major randomized trials have compared UF against diuretics in ADHF, over the last eight years. The first one was the RAPID-CHF trial.  The primary end point was weight loss at 24 hours. A larger trial was published in 2007, the UNLOAD trial. Both these trials showed a greater rate of fluid loss with UF than diuretic use. The UNLOAD trial also showed fewer rehospitalizations at 90 days, for the UF group. From a renal perspective, there was no significant increase in creatinine with UF reported in either trial.

The results from the above two trials really made UF almost a “first line” treatment for ADHF. On top of it all, I saw data from a study in Italy increasingly (and perhaps, erroneously) getting extrapolated to UF use for treatment of ADHF. Essentially, the Italian study had shown that intermittent hemodiafiltration could increase diuretic responsiveness and reduce the level of inflammatory cytokines.  Equating hemodiafiltration to ultrafiltration would make me cringe as I struggled to explain the difference to my cardiology colleagues!

Finally, we had the CARRESS-HF trial late last year which tried to answer the same question in a slightly different way (stepped algorithm for dosing diuretics vs UF). At 96 hours, there was no significant difference in weight loss between the two groups. The primary end point of increase in serum creatinine was significantly worse in the UF group.  The UF group also showed a significantly higher rate of other serious adverse events (eg, bleeding, anemia, thrombocytopenia, dyselectrolytemia, sepsis, heart failure). There also was a trend towards higher mortality for patients who received UF.

Given the relatively recent nature of the evidence against UF, it might be some time before we see a universal change in clinical practice. So I guess we nephrologists will continue to see patients of refractory ADHF with AKI, where perhaps diuretics weren’t used in a stepped fashion, or UF was used early. At this time, the American College of Cardiology recommends that UF be used only as a second line treatment for patients who do not respond to diuretic optimization.   

I am curious to know what your experience has been in this setting? Have you experienced a difference of opinion between nephrologists and cardiologists?  

Posted by Veeraish Chauhan

Real improvements in concussion treatment

The CDC reports that approximately 200,000 sports-related concussed athletes per year end up in US emergency rooms.  The total number of sports-related concussions is five times that figure.  Whether the patients end up in EDs or not, our diagnosis and treatment of these traumatic brain injures is substandard compared to what might be possible. 

I recently heard an excellent story about cooperation between the Cleveland Clinic and the Allegheny Health Network to enhance the diagnosis and treatment of concussed athletes and others.  The work being done has great potential to reduce the danger of concussed players returning too soon to the game and to prioritize post-concussion treatment. And it is based on iPads and apps.

The presentation was by Jay Alberts of the Cleveland Clinic--where the development work took place--and Keith Lejeune, Vice President of Innovation Deployment at AHN. It turns out that the accelerometer and gyroscope in the iPad makes concussion assessment possible. But the program starts before any injury occurs.  This story from radio station WESA explains.

C3 Logix is a new, innovative concussion evaluation technology that provides on site data collection at the time of injury, to better aid physicians in diagnosis and treatment. The program is loaded into an iPad and before the season starts, athletes perform a series of neurocognitive tests. The program tracks the athlete’s visual reflexes and their ability to focus on moving objects. Results of these baseline tests can then be compared to data logged in incident reports at the time of suspected brain injury.

After an injury, by having the patient wear the Ipad on a belt, you can watch minor variations in movement and balance that are indicative of whether the brain has recovered fully. Feeding data directly into the electronic medical record, this electronic format enhances understanding of cognitive and motor declines for a concussed patient.

The app on the Ipad creates an avatar to help visualize the balance issues being faced by the concussion victim. You can thereby show this to coaches and parents, too, to help them understand the extent of the injuries.The radio story explains:

The information that C3 Logix provides is key because the athletic trainer or doctor doesn’t have to rely solely on the testimony of an injured player, whose main priority might be returning to play.

During the recovery period, the neurocognitive tests are also repeated  to monitor improvement over time. It turns out that patterns or recovery vary widely among patients. Patients can be referred to physical therapists or speech therapists as data indicate ongoing need. Previously, treatment was based on the "Rest and Pray" model. The empirical result of this has been much more use of extended care (e.g., PTs) than previously would have been the practice.

Compare this to the usual assessment.  An athlete is injured.  The trainer takes care of the person at the site.  Later, the patient shows up for follow-up, but the initial information collected by the trainer is not highly quantified, and it is certainly not captured in the EMR. There is no way for the follow-on caregiver to know the extent of the injury at the start, much less compare the athlete to his or her baseline conditions.  Even the work-up at the ED or clinic fails to produce and capture for future comparison a highly quantifiable version of the facts.

Spread of this approach is proceeding apace.  WESA reports:

C3 Logix is currently used at more than 50 schools in northeast Ohio and has been used to assess more than 7,000 athletes in the past year. Athletic trainers at Allegheny Health Network began baseline testing with the system this month, and there are plans to expand the C3 Logix program to all 14 school districts that receive their training services. The system is also being used at Robert Morris University and by the Pittsburgh Riverhounds soccer team.

Here's a descriptive video story from KDKA television:

Sunday Dialogue: Responses and Rejoinder

Artwork by Marion Fayolle at the New York Times

The New York Times has reposted my initial letter to the editor in their Sunday Dialogue feature, plus responses to it, plus a rejoinder from me (at the end).  Check it out here or in your actual Sunday morning paper.

My last word:

As a general matter, if you can characterize an error or near miss by saying, “It could have happened to anybody,” that is a pretty good indication that it reflects a systemic, rather than a personal, problem. 

The Waiting Room comes to PBS

Excerpts of a note from Pete Nicks:

We proudly announce that The Waiting Room finally hits TV screens nationwide on PBS' Independent Lens this Monday the 21st of October at 10pm!
(check your local listings).

It has been quite a journey since Bill Hirsch and Scott Verges, two local attorneys who wanted to make a film about the uninsured, hatched this idea in 2007. And like any good story there were ups and downs. After struggling to figure out how to tell the story, raise the money, get through production and then a daunting 14-month edit, we were rejected by 22 festivals! But starting with our friends at True/False in Columbia, MO and through an amazing run at the San Francisco Film Festival the film began to find its voice and roared all the way to the Oscar shortlist! That was truly something to behold and it would not have happened without the faith and determination of a lot of people.

So now, this Monday at 10pm our little film will get a big audience. You can do your part simply by watching this film, talking about it and encouraging others to do the same. Because after all, we're all on this journey together.

What are you waiting for?

best,
Pete Nicks and The Waiting Room team

Misplaced priorities?

In an emergency, time matters, right?

The following recorded message is currently being provided when you call a local primary care clinic.  It clearly was just dropped in before the regular message. There is no way to bypass it. Did someone forget about the medical emergency advice that usually comes up front, or was there a conscious decision to push it back?

I understand the challenges that clinics face in providing clear, concise, and current patient information.  I wonder how other places have solved this particular problem.

Thank you for calling [name].  At the present we are offering the flu vaccine for all patients interested in obtaining it.  If interested, please be sure sure to ask your doctor or nurse practictioner for it during your visit.  We also have a walk-in clinic available for you in [location] from 8:30 am until 5:00pm.  The flu shot will be charged to your insurance.

Please remain on the line for our main menu.

Thank you for calling [name, repeated].

[30 seconds in] If this is a medical emergency, hang up and dial 911 or your local medical response number.

Two hard weeks here

All communities have their tragedies, and this month brought two to our town.  First, a student from Newton North High School took her life about two weeks ago; and on Wednesday, a sophomore at Newton South High School was found dead. My friend Lori Berman Gans reflected on these events to her friends in an eloquent post on Facebook.  I think she has it right:

It's been a hard, sad week in Newton. For parents of teens, it's something more as well. High school is a big transition for the kids, but it's a harsh entry to a new reality for us as well: seeing our children suddenly exposed to the the dangers, the fragility of their lives that we’ve spent their entire childhoods trying to protect them from. This is our new reality, and parenting suddenly requires a set of skills that run counter to every instinct. There will be more awful news -- drugs, alcohol, arrests, car accidents, and, God forbid, more losses. As parents, we need, at these moments more than any others, to cling to our babies, to promise them that nothing will ever hurt them, that the magical thinking of their youth still can work if they just stay close, hold our hand and trust in our parental superpowers. We might even convince ourselves. Instead, the best we will do is embarrass them with affection they don’t want, advice they don’t think they need, and trust they may not even fully deserve -- the opportunities to make mistakes if only to prove to them that we’ll be there to help them figure out how to crawl out of whatever holes they dig for themselves and the kick in the pants to get them to do it for themselves. What else can we do? Deep sigh. It’s been a hard, sad week for us all -- but I can’t even begin to imagine the pain those two families are going through, and all the agony yet to come, as they search for answers that may or may not ever be found.

Diabetes: To Biopsy or not to Biopsy - Part 2

In my experience the appetite to biopsy patients with clinical renal disease varies widely between clinician, institution and country. This is most apparent when it comes to the diabetic patient with renal disease. In my opinion there is a fear among nephrologists of biopsying patients with potential diabetic nephropathy (DN). Of course there are clinical features that increase the likelihood that a diabetic with renal disease has DN. Retinopathy in a type 1 diabetic, longstanding DM and progressive proteinuria over years preceding an elevated creatinine. However, the role of microalbuminuria and proteinuria in predicting CKD progression and the traditional course of rising albuminuria in DM1 has been challenged. In DM type 2 the picture is less clear and these patients frequently have many comorbidities. Gearoid posted on this subject about a year ago now. In CJASN (October) Sharma et al from Columbia University reviewed the characteristics and renal diagnoses in 620 diabetics who had a renal biopsy. Over 90% had type 2 diabetes. In Columbia in 2011 approximately ¼ of all biopsies were on patients with diabetes. The results of this retrospecive review were that 37% of patients had DN alone, 36% had non-diabetic renal disease (NDRD) alone, and 27% had DN plus NDRD.

In NDRD alone: FSGS (22%), hypertensive nephrosclerosis (18%), acute tubular necrosis (ATN) (17%), IgA nephropathy (11%), membranous GN (8%), and pauci-immune GN (7%) comprised 80% of diagnoses.

In DN plus NDRD: ATN (43%), hypertensive nephrosclerosis (19%), FSGS (13%), and IgA nephropathy (7%).

In multivariate analysis longer duration of DM was associated with a greater likelihood of DN and less likelihood of NDRD.

The table illustrates the features of patients at the time of biopsy. Older age, having DM2 vs DM1, short duration of DM and less proteinuria are more likely in those with NDRD alone vs DN alone in this cohort. 

I think this study highlights the importance of considering biopsy in diabetics (especially type 2). I would be interested to hear about the experience of others with respect to biopsy in diabetics.

Posted by Andrew Malone

Characteristics	DN Alone	DN Plus NDRD	NDRD Alone
Participants (n)	227	164	220
Age (yr)	59 (49–65)	63 (55–72)	63 (54–70)
Male sex	129 (56.8)	100 (61.0)	142 (64.6)
Race
Unknown	108 (47.6)	57 (34.8)	104 (47.3)
White	62 (27.3)	63 (38.4)	70 (31.8)
African American	39 (17.2)	33 (20.1)	29 (13.2)
Hispanic	12 (5.3)	7 (4.3)	8 (3.6)
Asian	4 (1.8)	4 (2.4)	7 (3.2)
Other	2 (0.9)	0 (0.0)	2 (0.9)
DM type 1	9 (4.0)	5 (3.1)	2 (0.9)
Duration of DM (yr)	13 (8–17)	10 (7–18)	5 (3–10)
Serum creatinine (mg/dl)	2.3 (1.6–3.8)	3.1 (1.7–5.2)	2.3 (1.5–4.4)
eGFR (ml/min per 1.73 m2)	31.3 (17.5–55.2)	21.4 (12.5–46.6)	32.5 (14.3–60.0)
Proteinuria (g/d)	5.0 (2.8–8.8)	5.0 (2.0–8.0)	2.9 (1.4–7.1)