Archive for April, 2013

Hospital care, urban and rural: issues in the U.S. & China

Friday, April 19th, 2013

I recently mentioned a study that examined results from a large number of medical care sites, some in cities and some in the country. That led me back to an April 3, 2013 JAMA article, "Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non-Critical Access Hosptials, 2002-2010. I must confess I didn't read this study the first time I scanned through that edition of the Journal of the American Medical Association (AKA JAMA). In fact, as they say, "my eyes glazed over" when I read the ponderous title.

You won't see this hospital in the countryside

You won't see this hospital in the countryside

But then I started to think of my time at Duke, 1966-1970, and its associated Veterans Administration hospital, the Durham VAH. That was clearly an urban setting , but sometimes, when I was on a VA rotation, we'd get a transfer from a different veterans' care facility, one located in the country. Now, in 2013, I fully understand the VA system has been markedly upgraded; then, in the late '60s, there appeared to be a quantum gap between the university-associated VA a few blocks from Duke's main hospital and the one, as we said in our smug way as residents, "out in the boonies."

In retrospect, that was also true of transfers from civilian rural hospitals to Duke University Medical Center itself. It had much less to do with the VA than it did with location.

Today nearly a fifth of our population lives in rural settings and 16 years ago our Congress set up a system to ensure that 20% would have access to hospital care. I've read parts of the legalese, 42 CRF 485, Subpart F, that was the origin of the system, termed the Critical Access Hospital Program. In essence it defined a series of small facilities (no more then 25 beds) located 35 miles or more from the next inpatient facility (shorter distances allowed for mountainous roads). By 2010 nearly 25% of our hospitals fit the CAH definition; with exemptions granted to the various states, only 20% of those CAHs meet the initial distance requirements. The program gives them reimbursement advantages while exempting them from national quality improvement programs.

That last section made no sense to me. If we tried to upgrade healthcare for the estimated 6o million of us that live in rural areas, why wouldn't we insist that those small hospitals join in whatever country-wide care-improvement programs that the urban facilities were mandated to participate in?

I went to the references on that issue; one came out in JAMA in 2006 with the title "Relationship between Medicare's hospital compare performance measures and mortality rates.

The JAMA article looked at large numbers (1.9 to 4.4 million) of patients admitted to the CAH hospitals and to non-CAH hospitals for three common major illnesses: heart attacks, congestive heart failure (the short definition per the Mayo Clinic is your heart can't pump enough blood to keep up with your body's needs) and pneumonia over a ten-year period. They specifically looked at death rates and concluded they were worsening in rural areas and improving in urban ones.

Then I thought about healthcare in rural China. I don't want to live there, but I keep being impressed by some of the things that huge and highly populated country is doing. But I've been aware that of the 1.3 billion inhabitants, half live in rural settings and don't share in the advantages that appear to be happening in urban areas.

Medicine comes to the farm and village

Medicine comes to the farm and village

So I Googled "rural healthcare in China" and found two articles of interest. One from the Bulletin of the World Health Organization in 1993 and said the barefoot doctor initiative had been faltering, the rural cooperative medical system was falling apart, there was an increase in poor, uninsured elderly and the 1978 policy shift to "Fee for Service" had favored the urban workers.

I found a recent update from February, 2013, in the Wall Street Journal online.  I subscribe to the paper copy of the WSJ, but was originally asked to pay $21.99 a month more for digital access. Finally I was given a way to look at the article free, but in order to print it would have had to order 50 copies. So I took notes instead.

China spent $125 billion since that 1993 timeframe and now 95% of its people have healthcare insurance and I bet they don't call it "XiCare." There are still huge disparities between rural and urban medical care and Health Minister Chen Zhu says they are encouraging doctors who've recently retired to take a stint in the rural areas, offering free education to new physicians who are willing to work there and (I wonder about this one) planning to lower exam standards for those to "aim to work in villages."

They clearly see a need to improve their insurance coverage rates for severe medical problems; at present a villager with a catastrophic illness still has to pay 30% of the bill.

So both countries have a way to go, but at least have looked at the issue of disparities in how we take care medically of those who live in the city and those who live in a village or on a farm. We've got ~ a fifth of our citizens (and non-citizens) living out there; China has a worse situation with half of its population in the countryside.

It will be of great interest and equal importance to see who solves the problem and how.

Maybe, just maybe, we can learn from each other.


Lessons unlearned

Thursday, April 18th, 2013

I weighed 153 pounds this morning, so I'm back on my diet plan until I'm under 150 again. Today I had fruit and cereal for two meals and a small amount of Thai leftovers plus a considerably larger amount of spinach for my big meal. I also went to our  health club and rode a recumbent bike for long enough to burn 500 calories and "cover" 15+ miles. I shoveled snow, wet heavy snow at that, for our house and our elderly neighbors place three times (we've had over 20 inches of snowfall in the past three days).  And of course, as I've mentioned before, I quit smoking in 1964.

This is not what we eat.

This is not our typical meal.

After diner I looked at recipes from Martha Rose Shulman's book, The very best of Recipes for Health. Shulman writes a healthy food column in the New York Times online version. I've looked at it frequently and we recently purchased her book. Lynnette made a Quinoa and Tomato Gratin yesterday and we immediately added it to our "Keeper List." A lot of the recipes are vegetarian (about 1/3 of our main meals fit in that category), but she's got some turkey and fish dishes.

What sparked this column was a Pure Study report in JAMA dated April 17, 2013. The title is lengthy: "The Prevalence of a Healthy lifestyle among Individuals with Cardiovascular Disease in High-, Middle-, and Low-Income Countries" In 2009 an article in the American Heart Journal described the PURE Study, the Prospective Urban Rural Epidemiology Study. The World Health Organization defines epidemiology  as the analysis of the distribution and determinants of health-related states or events (including disease), and the application of this knowledge to the control of diseases and other health problems.

The PURE Study began with a premise we're all (hopefully) familiar with; over the past 50-60 years we've seen an epidemic of obesity, diabetes and cardiovascular disease in much of the world, especially in countries, like the United States, where many smoke, eat too much of the wrong foods and exercise too little

Let's start with smoking in this country. The CDC published data online from a 2010 study that said over 19% of adult Americans smoked cigarettes. Over a fifth of those aged 18 to 64 were in this group, but only 9.5% of those over 65. Hispanics (12.5%) and Asian-Americans (9.2%) did better than whites or blacks, but over 30% of American Indians and Alaska Natives were smokers.

Smoking percentages went sharply down with more education: 45.2% of those with a GED smoked, 23.8% of those with a high school diploma, under 10% of people who had graduated from college and 6.3% of those with a postgraduate degree.

Similarly those living below the poverty level were more likely to be smoker (28.9%) than those with incomes at or above that level (18.3%).

There's lots of data linking obesity, low-quality diets, and lack of exercise with cardiovascular disease including heart attacks and stroke. How one defines a low-quality diets varies around the world; living here, I thinks it's lots of fast food and little emphasis on fruits and vegetables.

As a young physician I saw many patients who didn't seem to get the message that their unhealthy lifestyle may well have contributed to their cardiovascular disease. When I was 53 my four-year-older brother died of a heart attack. Almost all of the rest of the family lived to 90 or longer, but he had smoked two to three packs of cigarette a day, gained fifty or so pounds and seldom exercised. If I had a heart attack or a stroke and survived, I'd look closely at my risk factors and try to do something about them.

The PURE study following over 150,000 adults (ages 35 to 70) in over 600 urban and rural settings in 17 different countries. This article discussed 7519 participants who had already had either a stroke or coronary artery disease and determined if they had stopped smoking, altered their eating habits and/or gotten more exercise.

The results were striking, but not at all amazing to me. Guess what proportion improved in all three arenas.


Over fourteen percent of these post-cardiovascular-event adults didn't take up any of the three logical behavior changes.

That made no sense to me. Could it be genetic pre-programming? Let's look at data on one of the three behaviors.

A rodent exercise machine

A rodent exercise machine

The New York Times had a recent online article titled, "Why we're motivated to Exercise or Not." Scientists at the University of Missouri took ordinary lab rats and put running wheels in their cages; They bred the males and females who were the most active to each other and did the same to those who ran the least. They continued this over ten generations and ended up with two disparate groups: one ran ten times as much as the other.

They examined the physiques of the rodents to see if one group was fat or had poor muscle tone: no significant differences were found. Then they examined genes in the reward portion of the rats' brains; the part that gives motivation to do things because they cause enjoyment. Lots of differences were noted here.

Does that mean those of us who exercise do so because we're genetically predisposed to do so and the rest are doomed to be sluggards?

The lead investigator, Dr. Frank Booth, thinks it's quite probable that humans have a genetic motivation to exercise or not. But he's quoted as saying his results "are not meant to be an excuse not to exercise."

And that's without having the added incentive of having had a heart attack or a stroke.

What does it take to change our habits of a lifetime?








My prostate and yours: benign and malignant

Wednesday, April 10th, 2013
At my age, I'm not scheduling this.

At my age, I'm not scheduling this.

I just printed an article from the Annals of Internal Medicine that confirms my own leanings toward prostate screening tests. In one of my old posts I told the story of having an abnormal blood test for kidney function and seeking out our senior urologist at Duke. I was a clinical Nephrology fellow at the time and when I was seen, the Chief of Urology asked what kind of diet I was on.

I groaned at that point since I realized I was in the middle of a research project and eating a very high-protein diet. That's why the more accurate of the two blood chemistry tests was entirely normal and the other, clearly influenced by my diet, was high.

He then said, "As long as you're here, Peter, let me check your prostate.

The digital rectal exam (DRE) revealed I had a mildly enlarged gland for my age and the urologist said, "You're going to have a TURP by the time you're sixty.

I knew a TURP was a transurethral resection of the prostate. If you look at the Mayo Clinic website I've provided, you'll see it's a procedure to relieve partial obstruction of the urethra, the tube that runs from the bladder through the penis to allow normal urination. The prostate itself, whose major task is to provide seminal (sperm-carrying) fluid, is a walnut-shaped, one ounce gland, or at least it is in younger men. As men age the prostate commonly enlarges. If it does so in a non-cancerous way, the condition is called BPH, benign prostatic hyperplasia (or hypertrophy as I was taught in medical school; the first term implies more cells; the other a bigger gland without specifying how it got that way).

As the prostate gets bigger and partially blocks the outflow of urine, men have a decreased urine stream, difficulty starting its flow, dribbling after urination or a more frequent need to pee, especially at night.

Urologists do about 150,000 TURPs a year in America, although there are a number of other procedures to treat BPH. And they want to do a DRE and draw blood for a PSA on more of us guys than I would agree with. There are other tests in their repertoire: rectal ultrasound, urine flow study and cystoscopy (inserting an instrument into the urethral to actually look at how narrow the passageway is).

The American Urological Association's (AUA) webpage on the surgical management of the condition says 88% of men who have a TURP will have significant improvement in their symptoms. But there are lots of complications that can occur right after the procedure: infection in 15%, bleeding requiring blood transfusion in 5-10%, impotence in 14%, incontinence in 1%. Ten percent may require a second operation within 5 years.

There also are medical therapies for BPH; I take two different pills a day for my BPH and will turn 72 in two weeks. I haven't needed a TURP yet.

But that's benign disease: how about prostatic cancer?

The ACP says there's debate on screening; what does your physician think?

The ACP says prostate cancer screening should be individualized; what does your physician think?

The recent Annals article I mentioned looked at four sets of prostate cancer screening recommendations, all from national organizations: the American College of Preventive Medicine, the American Cancer Society; the AUA and the U.S. Preventive Services Task Force (USPSTF).

After doing so, the Clinical Guidelines Committee of the American College of Physicians (ACP), a national society of internal medicine physicians, issued two guidance statements. ACP wants all clinicians to tell their male patients who are 50 or older and under age 70 that the positive effects of screening for this malignancy are limited and there are considerable potential negative effects.

That being said, if I were an African American man in that age range I'd be much more likely to ask to be screened. Both the incidence rate and the mortality rate from prostate cancer are higher in black men. And if I had a family history of the disease in a first-degree relative (father, brother or son), I might be first in line for a PSA and possibly a DRE. With one such having had it, my risk doubles and with two close relatives having the disease, my chances go up fourfold. That's especially true if they were diagnosed before they turned 65.

Overall a sixth of all men will eventually be diagnosed with cancer of the prostate. It will lead directly to death in a much lower percentage (2.9% was the figure the ACP quoted from a National Cancer Institute fact sheet). So although 2.3-2.5 million men in this country are living with this malignancy and last year nearly a quarter of a million got the diagnosis of prostate cancer in the U.S., a considerably smaller number were likely to die from the cancer itself.

Why does this make sense?

Well let's start with the second of the ACP's guidance statements: the organization says that men with an average risk of the disease shouldn't be screened until they are 50 and those of us 70 and older also should avoid having a PSA as a cancer screening tool. They go further and say men who are not expected to live more than 10 to 15 more years also should not be screened.

The fact sheet from the Prostate Cancer Foundation says it is the most common non-skin cancer in America with a new case very 2.2 minutes and a death every 17.5 minutes. But it's rare in men under 40 with 1 in 10,000 being diagnosed with the ailment versus 1 in 14 who are aged 60 to 69.

If we look at the totals: 97% of men diagnosed with prostate cancer are 50 or older and nearly two-thirds  are over 65.

The USPSTF came out with an update to their take on screening guidelines in 2012. They agree that the benefits of these tests, primarily the PSA, are less than the potential harm associated: false-positive tests, psychological effects, biopsies that are not necessary and over-diagnosis of cancers that often do not reach any clinical significance in the lifetime of the patient involved.

In other words, elderly men may well have prostate cancer, but they most commonly die from something else. And screening men at age 40, as the AUA suggest, doesn't appear to be based on any major studies.

If you are a man over 50, but less than 70, or black or first-degree relatives (father or brothers) have had the disease, have a sincere talk with your doc about the risks and benefits of screening.

But I don't fit into any of those groups, so I don't plan to get a PSA unless or until I see different data.

Thank you, ACP, for clarifying the subject, especially since you agree with me.



But won't I gain weight if I quit smoking? You may die if you don't.

Wednesday, April 3rd, 2013
A sign for our times

A sign for our times

Half of those who smoke die before their time. And there's a direct linkage between their smoking habit and the diseases they die from.

I stopped smoking as a junior in medical school forty-eight years ago. I was helping take care of a Veterans Administration cancer ward and saw one of our patients, smoking through his tracheostomy. I had only been a smoker for two years and had been thinking of quitting: that visual image cinched the matter.

My father, who lived to almost ninety-five, gave up the habit as a young doc. One morning he realized he had ashtrays in all three rooms of his medical office and a cigarette that he had lit was burning in each one. He snuffed all of them out, threw his pack of "cancer sticks" away and got rid of the ashtrays as well.

A May 2010 fact sheet from the World Health Organization (WHO) with the simple title "Tobacco," states the clear-cut, nasty facts. The noxious weed kills almost six million people a year; in all smoking leads to one out of every ten adult deaths. WHO states that ten percent of those are nonsmokers who've had the misfortune to be exposed to second-hand smoke. They breathe in some of the 4,000+ chemicals in tobacco smoke with a least 250 of those known to be harmful and more than 50 known to cause cancer.

But there is even worse news; over 40% of kids have a parent who smokes and those kids are among the group exposed to all those dangerous chemicals from second-hand smoke. One estimate is that ~30% of those who die from second-hand smoke are children.

Overall, the World Health Organization says tobacco caused 100 million deaths in the 20th century and, unless something changes radically, our smoking trends worldwide could lead to a tenfold increase in those deaths in the 21st century. Current estimates say there are at least one billion smokers across the globe and roughly eight of every ten of those live in low- and middle-income countries. We've got a considerable share of smokers in this country as well, many of them are relatively young.

Growing the plant raises another problem for children. Although most of the world's tobacco is raised elsewhere, with China Brazil and India leading the pack, the United States still has a $35 billion per year industry for the "pernicious weed" with 303 billion cigarettes sold in 2010 and 122.6 million pounds of smokeless tobacco. The kids who live in regions that raise the plant are often employed in cultivating and harvesting it.

Don't handle these in any form, kids!

Don't handle these in any form, kids!

Those children are potential victims of green tobacco sickness (GTS), even if they don't smoke or chew it themselves. The occupational disease they contract is actually acute nicotine poisoning and reports of cases in children and adolescents have been reported only in the US in the medical literature and rarely even there.

Agricultural occupational illness, for example from pesticide exposure, is well known, but the risk factor is ordinarily not  plant itself. In the case of tobacco (as is the case for opium) the crop is actually the major biohazard, with a major component being the nicotine dissolved in rain or dew on the tobacco leaves. Children usually haven't developed tolerance to nicotine like long-term adult smokers have and frequently lack any knowledge of the risks involved in handling the leaves of the plant.

Nausea, vomiting, headaches, weakness and dizziness are among the symptoms of GTS. It's quite uncommon for the affliction to be severe enough to be fatal, but the 2005 report above quotes a child who said he felt, "like I was going to die."

With most of the world's production of tobacco coming from outside the US, especially in developing countries where pediatric emergency and intensive care is considerably less available, much more attention needs to be paid to the risk factors for GTS and potential strategies for its avoidance.

JAMA, the Journal of the American Medical Association, recently (March 13, 2013) published a research article and two other commentaries on smoking cessation.

One of the reasons, actually rationales (or better yet, excuses) smokers give for not quitting is, "I'll gain weight and that's just as bad for my health!" An article with the ponderous title "Association of Smoking Cessation and Weight Change with Cardiovascular Disease Among Adults With and Without Diabetes," attempted to parse this belief. The short take on this article is available online on an NIH webpage. Data was gathered on cardiovascular disease (CVD) events and weight gain among 3251 Framingham Offspring Study participants followed for a mean time of 25 years (the study ran from 1984 to 2011).

Smoking cessation was associated with a considerably lower risk (about half) among those in the study who were not diabetic. Long-term weight gain was mild (typically a couple of pounds after an initial bump of perhaps five pounds) and did not affect the CVD benefits of stopping smoking.

An associated question, "Helping Smokers Quit Around the Time of Surgery," was discussed by three academic physicians, one from Yale and two from UCSF. It is common for smokers to have no pre-operative counseling on cessation programs before they have elective surgery, yet their post-op complication rate is markedly higher if they haven't quit.

Two randomized, controlled studies, one in Lancet in 2002 and the other in the Annals of Surgery in 2008, have shown a marked decrease in after-surgery problems, including pneumonia, wound infections, strokes and heart attacks, through a 4 to 8 week pre-op smoking cessation program. .

It's clearly time to focus our attention on the huge issues associated with growing, harvesting and smoking/chewing tobacco.  The enormous health costs involved are well worth our best efforts.

Otherwise ten million surgical patients (in this country alone), children workers in the tobacco industry in many countries, all those who are hooked on the weed and those of us exposed to second-hand smoke will continue to be at risk.