Wednesday, October 15, 2014

Readmissions: Sometimes it's the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

We've all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time it's the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say it's the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didn't take their meds at all.

I know someone with type 2 diabetes who doesn't watch her weight or what she eats and doesn't check her blood sugars. She says, "You've got to die of something. I'd rather live my life the way I want to."

Is it that doctors and nurses aren't educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Here's something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I don't know, but sometimes the problem is the patients.


Chris Porter MD said...

OB hotline where I did my rotation claimed a patient called, surprised with a pregnancy. She'd been using spermicidal jelly routinely - on her morning toast.

Skeptical Scalpel said...

Isn't that how you are supposed to use it? I'm glad I wasn't eating or drinking when I read your comment. I would have aspirated for sure.

frankbill said...

One reason may be side effects of B/P meds. If your choice is to have slow heart rate or shortness of breath on meds. Can tell you this is no fun. One may find they get to the point where they stop taking meds just to feel better.

Skeptical Scalpel said...

Frankbill, I am not an internist and never treated hypertension, but I would say that if a patient is having intolerable side effects from a drug, it would be best to discuss the problem with the prescribing doctor instead of simply stopping it.

frankbill said...

I do agree should try to work with prescribing Dr but many Dr are slow to change ones meds.

Moose said...

Argh. As a type II insulin-dependent diabetic, nothing drives me further up the wall than diabetics who somehow think that the disease means giving everything up. However, the medical professionals are sometimes to blame for this. So is the mass-media.

Both continue the ancient beliefs: You must lose weight. You must diet obsessively. You must give up all sugars. I heard all of this when I was diagnosed, plus that if I didn't do these things I would be blind, have amputations, and be dead within 10 years. That was 22 years ago.

You do not have to lose weight, although if you can it will improve insulin resistance. However, you MUST exercise, which will also improve insulin resistance as well as improve overall cardiovascular health.

You do not have to obsessively diet. You DO need to learn to eat in a healthy manner. You DO need to learn the difference in carbs, and how each carb affects you (which is different for every person). You DO need to spend time learning how to juggle foods in your diet, but you do not have to give up anything. Everything in moderation.

The American DIabetes Association, at some point, woke up and realized that telling people "never eat this!" not only makes foods forbidden fruit, but is bad for mental health. Even folks strictly following the ADA diet are encouraged to occasionally have a treat. Want some ice cream with dinner? Do your carb & fat exchanges and have at! A high-protein, low-carb salad and some chocolate chip ice cream is a wonderful meal.

As far as testing -- one of the things I've found over the years, talking to other diabetics, is that the best way to encourage more testing is to use something that juvenile diabetics are taught: There Are No Bad Numbers. You test to see how a combination of foods affect you. You test to see if your medications are working or need to be adjusted. You test to see what needs to be modified, not to see if you're "bad" or "good." Unfortunately, too many medical professionals see high numbers and blurt out "This is bad!" (Worse, I've seen some more concerned over a 500 than a 50.) To get patients to test more we need to get rid of the guilt and encourage it as a pro-active behaviour.

frankbill said...

Most internists have limited knowledge on treating hypertension.
Since I use the VA for health care Dr Grim came up with this example as to what it can take to get the right drugs that may work for treating and having side effects one can live with.

we know there are several classes of drugs used to treat HTN. And each class has several variations.
So lets say the VA limits the choices.

1. Diuretics: 4 choices
2. BB: 2 choices
3. ACEs: 2 choices
4. ARBs: 2 choices
5. CCBs: 2 choices
6. Central agents: 2 choices
7. MCBs: 2 choices.

So how many different possible combinations to try to find the right one that works for you.

Thus the first choice is 1 of 7. Then if single therapy does not work you have a permutation and combination problem.
As I recall the number of combinations you can make of these 7 is calculated by the following
Number of choices of one from each group = 7
Number of choices of two from the group of 7 = 42
Number of choices of 3 from the group of 7 = 210
Number of choices of 4 from group of 7 = 840.

So we sum these a and get 1549 different combinations and permutations we would have to go thru before deciding you are a treatment failure.

frankbill said...

The JNC 8 guidelines Now says that in some can stop or reduce med if over 60 as B/P goal is now 150/90 up from 140/90.

frankbill said...

I think there are two problems here. One is communication the other is trust.

Both the Dr and patient have be able to communicate with each other. This seem like it should be easy to do but if one reads what is put in there medical record they may get a surprise. What they said and what the Dr writes about he thinks you said are not always the same.

The trust part depends on many things. Today it is very hard to build trust in a 15 min. visit. would you trust a Dr that can't remember the name of one 4 meds you are on even though this is the med you are talking about?

Skeptical Scalpel said...

Moose, good points about diabetes. Thanks.

Frankbill, I agree there are a lot of choices. I still would not advise unilaterally stopping a drug. I agree with others who have observed that mild hypertension is over treated.

Anonymous said...

what happens when patient can't afford medications and is making trade offs?

Anonymous said...

Thanks Anonymous,

I also had a hard time paying for medications. Actually it and one other item has sent me into trying to pay for that medical issue and I've had financial issues ever since. No one bothered to ask me, they just blamed me.

After being booted out and saying I needed to see some results because I couldn't pay for things that didn't help (and I had paid several hundred dollars for it), I now just straight up tell docs if I can't afford it, I can't. If they boot me they boot me but after a couple of years and still in the hole trying to pay off, I have had it.

Yes, we do need to take our meds, but with a lack of trust, funds, side effects, we're getting tired of taking the blame.

Skeptical Scalpel said...

Anons, your point about the cost of meds is well-taken. I did not get into that and maybe I should have.

On the topic of hypertension as noted above, there are many effective drugs, some of which have been around for ages and are off patent. I realize some docs only want to prescribe the newest and most expensive drugs. But you need to make sure they are aware of your circumstances.

Also there are many drug discount plans out there and they charge no fee to the patient. Have you explored that possibility?

frankbill said...

The problem with the study is it is done on a very select group. They sate other reasons why study has several limitations.

To get better result of treatment of hypertension both PCP and patients have to get better educated. Patients need to take there B/P at home daily if possible. This lets patients see if meds are working.

Anonymous said...

Hey Skep,

Just wanted to say that the couple of drugs I had didn't get discounts. If you work, you can forget getting any discount, to be honest.


Skeptical Scalpel said...

Sorry for the delayed response. I needed to get some information.

Go to this website It is not a scam. The discount is real and possible because the pharmacy makes it up on volume.

frankbill said...

Walmart has many drugs that they only charge $4 per RX. This card may save you money on drugs But note can save up to 75%. So this could be any where from 0 to 75%. Saving something is better then nothing But still may not gets drug price down to where some can afford them.

frankbill said...

The cut off income for a single person for most low income programs is less the $19000 a year. Not much income by todays cost of living.

frankbill said...

There is no shortage of stupid things people do. Some of them may be a reasons for readmissions. Lets say after having keyhole surgery you start working out two weeks later and cause injury to your self.

If a case like this was to go to court all that would matter it what is written in the medical records. If it isn't stated to not start working out within a certain time then court may find Dr at fault.

Erica J. Thiel said...

As a patient with a complex and rare underlying genetic (storage) disorder and thus many secondary issues for me to be perfectly honest sometimes not taking cardiac meds on occasion is simply b/c of the side effects.... While I completely trust my Cardiologist I do feel drs need to be more willing to take in to account what pts. say about med side effects and work with us to find things that not only help our issues/symptoms BUT don't impede quality of life!

Doctors so frequently get on the 'You need to stay active, not let what you have stop you from living' bandwagon (thankfully not mine)
and yet often they do not really listen to what pts. say about med side effects....


Skeptical Scalpel said...

Erica, I can't deny that some doctors don't listen.

Orthopaedic Associates said...

Great read! We, as doctors can only do so much. It is a two way street that takes all parties to get the best results.

Skeptical Scalpel said...

Thanks. Your comment is appreciated.

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