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.

How many medications can a patient take?

Here is a list of medications that a 75-year-old patient is taking at home. All are orally taken except where noted.

Acidophilus 2 twice a day

Colace 100 mg twice a day

Coumadin 5 mg once a day

Detrol 4 mg once a day

Diflucan 50 mg once a day

Duragesic 12 ug transdermal patch every 3 days

Klor-Con 10 meq once a day

Lactulose 30 mL twice a day

Lantus 15 units subcutaneously once a day

Lasix 40 mg alternating with 20 mg every other day

Lisinopril 2.5 mg once a day

Metoprolol 25 mg twice a day

Multivitamin 1 tab once a day

Novolog Sliding Scale subcutaneously with meals [dose varies according to blood sugar]

Oxycontin 20 mg every 12 hours

Prilosec 20 mg once a day

Reglan 5 mg before each meal

Vitamin A 25,000 units once a day

Zoloft 50 mg once a day

Docusate 100 mg twice a day as needed

Hyoscyamine 0.25 mg sublingual every 4 hours as needed

Oxycodone 5 mg every 8 hours as needed

That’s 22 different drugs with a minimum of 24 pills per day and a maximum of 35.

With the Lasix and the sliding scale Novolog, do you think she ever misses a dose or takes a wrong dose?

The above patient is on three narcotics Duragesic, Oxycontin and as needed oxycodone. Add to those meds Zoloft and Reglan. I wonder if she’s drowsy or confused? I bet it will be a big mystery when she falls and breaks her hip.

What effect do you suppose 10 meq of oral potassium per day is having on her total body potassium [total body contains some 3000 meq of potassium] or even serum potassium?

This is not close to the record. I once was consulted on a patient who was on 31 different medications at home. I’m sure that someone has seen a patient taking more than 31 medications. Have you?

Many patients do not know what meds they are on

The other day I tweeted the following:

“How can a patient, who does not know what meds she is on or why, seriously participate in ‘Shared Decision Making’?”

I apparently struck a nerve with several followers who replied with tweets accusing me of not educating the patient, wondering why she doesn’t know, wondering if she might be on too many meds [ya think?], etc. One response was from a software developer who likened doctors to technology professionals, patients to computer users and computers to medications. None of those who confronted me is a physician. I am not sure what types of front line experience with patient care they have had.

Let me clarify a few things.

I am certainly not against explaining things to patients. I believe they should understand what treatments they are agreeing to. My point was I think a substantial number of patients do not really understand things even when they are explained at length.

I was seeing the patient as a consultant. I am not her primary care physician [PCP]. The problem of patients not knowing what medications they take is very common. An informal poll of some of my physician colleagues reveals that as many as 50% of the patients we see in our emergency department do not know what meds they are taking, why they are taking them and they do not have a written list of current meds in their possession.

Many studies show similar results. Researchers at the Mayo Clinic found that patients discharged from the hospital had significant problems recalling the names of any new meds prescribed or their dosages. A study of patients seen in the emergency department at UCSD showed, “Only 48% of patients could recall or produce a list or the actual bottles of all of their medications, 39% knew the times they take their medications, and only 24% knew all the dosages.”

The PCPs and hospitalists where I practice take great pains to educate their patients on the need to know their illnesses and medications. They have all been instructed about the importance of this and the need to carry a list of their medications at all times.

They simply do not do it. Why not?

I don’t know but I have some ideas. I practice in the real world. Most of my patients are nice people who are very down-to-earth types. Some are on too many meds. Some are old. Some are confused as a result of their illnesses and/or their meds. Some are anxious. Some are mentally ill. Some are “all of the above.”

But [you won’t like to hear this] many just do not want to take responsibility for their own health. I think they don’t know their meds for the same reason they eat too much, smoke too much, drink too much and don’t exercise.

Go ahead and blame us doctors for not educating the masses. I say, keep trying, but don’t be disappointed when half of them don’t comprehend the importance of what you are trying to do or possibly just don’t care.

While I’m on shared decision making, I have this final comment. Physicians should not present three options with lengthy dissertations on the myriad side effects of treatment and no real advice as to what would be best for the patient. You cannot teach someone the anatomy, physiology or the nuances of medical care in a shared decision making discussion. How can a patient make a rational choice without guidance from the physician?