August 19th, 2008 by Dr. Val Jones in News
8 Comments »
A small research study suggests a link between depression and poorer driving test scores. In fact, there also seemed to be a dose-response relationship with anti-depressants. In other words, the study subjects on the highest doses of anti-depressents got the lowest driving test scores.
Since depression can impair one’s concentration – the link is certainly plausible. I thought it was interesting that anti-depressants seemed to increase the risk for low scores. One would hope that those on anti-depressants were less symptomatic, but it’s also possible that the dosage correlated somewhat with the severity of the disease.
Drivers with conditions that could impact their driving abilities (such as epilepsy or stroke) should report their impairments to the DMV. Will the list of reportable impairments eventually include depression? I doubt it, but it is reportable to the Vehicle Licensing Agency in England.
On the spectrum of risk factors for sloppy driving, I wonder where depression stands?
- Cell phone usage
- Advanced age
- Driving in a foreign country
- Driving while eating/drinking
- Driving while intoxicated
It would be neat to see these risk factors compared to one another on a graph. Has anyone seen such a thing?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 16th, 2008 by Dr. Val Jones in Health Policy
5 Comments »
No one wants to become infected during their hospital stay. Unfortunately it’s not possible to guarantee that it won’t happen. Bacteria are everywhere. We carry them on our skin, in our bodies (especially our digestive tract), and they live in food, clothing, and anything we touch. When we undergo surgery, we cut through the skin/blood barrier that keep the bacteria out, making us vulnerable to inadvertent invasion.
There are ways to reduce the risk of infection (sterile surgical technique, appropriate wound care, and personal hygiene) but the risk is not zero. For the risk to be zero, one would have to begin with a “sterile” patient – a patient who carries no bacteria on or in their body. Since that will never happen, I’m afraid that hospital acquired infections are here to stay.
However, with government-sponsored health insurance programs on the brink of bankruptcy, decreasing expenditures is a high priority. Therefore, Medicare is suggesting that there are certain events that should never happen in the hospital and that they will no longer compensate hospitals for care associated with these events. Although I certainly agree that operating on the wrong body part is appropriately classified as a “never event,” the list has become so long that it includes things that cannot possibly be prevented in all cases (things like catching a cold, developing a blood clot, falling, or becoming infected).
What will result from listing infections as a “never event?” Will it encourage hospitals to improve their infection control processes? Maybe. But here’s what I imagine is more likely to happen:
1. More prophylactic antibiotics will be given to patients to reduce the risk of infection, resulting in higher rates of serious drug reactions. Stronger medicine (with broader coverage) will be preferentially selected – further encouraging the development of drug resistant strains of bacteria.
2. Patients who become infected will be transferred to another facility as quickly as possible. The accepting facility will be compensated for the care of the patient since the “never event” didn’t happen at their hospital. Transferring care in the middle of a serious illness increases the risk for other complications, including miscommunications and medication errors.
3. Since Medicare has set the expectation that hospital acquired infections are 100% preventable, anyone who contracts one will be able to sue the hospital. This will deplete the hospitals of their thin operating margins, causing them to cut programs – probably first for the poor and underserved.
4. Additional testing may be done for any surgical admission – nasal swabs (and potentially rectal swabs or urethral swabs) will be used to document the fact that the patient arrived at the hospital colonized by certain bacteria and therefore did not contract a new infection during their hospital stay.
5. Convoluted documentation methods will abound, so that any patient who becomes infected will receive antibiotics for “prophylaxis” and his fevers will be explained as the usual “post-op” central fevers. All staff will be encouraged to carefully document that the patient is being treated prophylactically only, and does not have an infection. In fact, it’s possible that blood cultures will not be drawn so that there will be no documentation of sepsis. Patients who really do have serious infections will receive appropriate care very late (since the first few days will be spent trying to manage the infection without documenting it or identifying the organism). This could paradoxically result in higher death rates.
6. Patients at higher risk for infection (such as those who are immunocompromised – see my research study on risk factors for line infections here) may be passed over for surgical procedures. This risk aversion could negatively impact health outcomes for vulnerable populations (such as cancer patients or HIV+ individuals).
I could go on theorizing, but you get the picture. In my opinion, the “never events” strategy is fatally flawed and will result in excessive litigation, ping-ponging of patient care, over-use of antibiotics, increases in adverse drug events, a rise in multi-drug resistant bacteria, and further reduction of services to the poor. A more reasonable approach would have been to document infection rates at the most hygienic facilities, and offer incentives for others to strive for similar rates.
The “never events” strategy is destined to do more harm than good for patients with hospital acquired infections, though the medical malpractice attorneys may enjoy a new income stream. This is just one more reason why we should never say never.
***
See Buckeye Surgeon’s take on this topic and his coverage of Jerome Groopman’s article for the New Yorker on the rise of drug resistant “super bugs.”
See Dr. Rich’s take on never events here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 14th, 2008 by Dr. Val Jones in Health Policy, News
2 Comments »
Methamphetamine (also known as “speed” or “meth”) is a fairly common drug of abuse in this country. The National Institute on Drug Abuse estimates that as many as 3% of 12th graders have tried the drug, and about 0.3% of the population actively abuses it. Meth stimulates the release of dopamine in the brain, which produces a feeling of intense well being, as well as increases in wakefulness, respiration, heart rate, blood pressure, and hyperthermia. It is very addictive, and its tragic, long-term effects include permanent brain damage, personality changes, psychosis, hallucinations, and impaired learning and memory.
While most meth is produced by “superlabs” in foreign countries, there are a substantial number of small, illegal labs in the US that produce it. Meth can be created by extracting pseudoephedrine (found in many cold and allergy medicines like Sudafed) and transforming it into meth via a chemical process that creates toxic environmental waste.
In order to clamp down on local production of meth, it is critical to control the diversion of pseudoephedrine from local pharmacies into illegal labs. The US government introduced a “Combat Meth Act” to improve the tracking of pseudoephedrine purchases, but some believe that this approach doesn’t go far enough. One successful anti-meth program in Australia (called the MethShield) is now being piloted in Kansas. I spoke with Shaun Singleton, the creator of MethShield, to learn more about how we can reduce meth production and sales in the US.
Dr. Val: Tell me about the Combat Meth Act and why it dovetails nicely with MethShield.
Singleton: The Combat Meth Act was introduced in 2005 and it has substantially reduced the number of meth labs in the US. The Act limits consumer purchase of pseudoephedrine to 3600mg of active ingredient per day (or 9000mg in a 30 day period). In order to purchase pseudoephedrine, you have to present a form of government-issued I.D. (like a driver’s license) and the pharmacist records that information and keeps it in a log book. However, since this information is not electronic, pharmacies don’t share information with other pharmacies, and so meth producers are able to present fake I.D.s and travel from one pharmacy to the next without anyone realizing that they’re over their legal limit. So unfortunately, people found a way to circumvent the Combat Meth Act and local production of meth continues to be a problem.
The MethShield is a real-time tracking program for pseudoephedrine sales. Instead of keeping paper records, it allows pharmacists to enter information into a secure online database. This makes it much more difficult for people to travel from pharmacy to pharmacy, purchasing their maximum allowed dose at each one. With MethShield the pharmacist knows exactly how much product the client has purchased in the past (from any participating pharmacy), and whether they’re eligible to purchase more or not. The information in the database is aggregated and made available for law enforcement to review.
Dr. Val: How do you protect patient privacy?
Singleton: First of all, you have to realize that we’re not interested in people who have a sinus infection, or use 50 Sudafed tablets per year. We’re talking about the 1% of people who are purchasing 20 packs of Sudafed in a day. Those people are the ones who are flagged by the MethShield system and are investigated by law enforcement.
The MethShield database offers superior privacy to current methods – which basically involve hand-writing peoples’ names in a binder and keeping it open on the counter top at the pharmacy (not very secure at all). MethShield was originally conceived and developed by the Pharmacy Guild of Australia and took great care to engineer the database in the most secure way possible. We ask for informed consent from clients and train pharmacy staff in how to maintain the database. In Australia we processed several million transactions during our pilot and did not receive a single privacy complaint. Most people are quite willing to give their driver’s license number to their pharmacist, understanding that the process might help to catch meth lab criminals.
Dr. Val: Can’t people just use fake I.D.s?
Singleton: We can’t stop people from using fake I.D.s, but the system renders them useless very quickly. Once you’ve entered one I.D. in the system to purchase 9000mg of pseudoephedrine, you generally can’t use it to buy more for another 60 days.
Dr. Val: Couldn’t the MethShield check the I.D.s against the DMV records to identify fake I.D.s more rapidly?
Singleton: Law enforcement officers can do this manually, but for privacy reasons the MethShield database does not connect to any other databases. Also, MethShield was designed to support pharmacists – so they can sell pseudoephedrine products safely – and it’s not really their role to be checking peoples’ I.D.s against a DMV database.
Dr. Val: What inspired you to create the MethShield?
Singleton: I’m married to a pharmacist and we live in Queensland, the once meth capital of Australia. I head a team that has devoted itself to creating IT solutions that make life easier for pharmacists, since they spend a lot of their time filling out forms to comply with government and insurance regulations instead of dispensing drugs and counseling people. We wanted to try to automate some of those processes to help pharmacists like my wife do what they’re really skilled at. We applied innovative thinking to kill two birds with one stone – to address the meth problem and free up pharmacists from some of their overly burdensome administrative tasks.
MethShield launched in November, 2005 and within the first 6 months of the program we were able to reduce the number of illegal meth labs detected by law enforcement by 23%. After 18 months we reduced the number of meth lab detections by 37%, and also had an increase in arrests and a number of charges raised. It’s really exciting to see such a visible impact.
Dr. Val: How are you planning to quantify the success of the program in Kansas?
Singleton: There will be 128 pharmacies in the pilot (as opposed to the 950 that we had in our Australian pilot program) and the success of the program really depends on the participation rate of the pharmacies. If they are careful to process all their transactions through the database we’ll get some meaningful data. Ideally we’d like to establish clear patterns of use and help the law enforcement agents to discern where the products are being abused. Law enforcement detected 97 illegal meth labs last year in Kansas, and we hope that the MethShield will further assist in the crackdown. If we can demonstrate the cost effectiveness of the program, we hope that Kansas will implement it state-wide.
*More about the MethShield*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 8th, 2008 by Dr. Val Jones in News
2 Comments »
Thanks to Dr. Deb for highlighting two interesting psychology research studies which offer new insight into lie detection. The first was conducted at my undergraduate alma mater, Dalhousie University, in Nova Scotia. After analyzing 697 videos of people reacting to emotion-evoking photos, researchers concluded that study subjects who tried to modify the natural response to a cute or alarming photo still retained flickers of the real emotion in their facial expressions. These “microexpressions” were identifiable by computer analysis of facial muscles, and may support the development of a new type of lie detector – a digital, facial expression analyzer.
The second research study found that people are less accurate in recounting false stories backwards than they are at describing a reverse chronology of true events. In other words, discerning truth from error may be as simple as asking someone to tell you what happened beginning at the end and working backwards. If they have a really difficult time keeping the facts straight – they are more likely be falsifying the information.
I don’t know if either of these lie detecting approaches (analyzing microexpressions or backwards story telling) will work on sociopaths and exceptionally good liars. But for the garden-variety fibber, they may just work.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
