July 30, 2009
July 14, 2009
Protecting doctors from lawsuits may do more to gain political cover for President Barack Obama’s health-care overhaul than to rein in medical costs.
While Obama vowed to address physicians’ malpractice worries in a speech yesterday, annual jury awards and legal settlements involving doctors amounts to “a drop in the bucket” in a country that spends $2.3 trillion annually on health care, said Amitabh Chandra, a Harvard University economist. Chandra estimated the cost at $12 per person in the U.S., or about $3.6 billion, in a 2005 study. Insurer WellPoint Inc. said last month that liability wasn’t driving premiums.
Obama told an American Medical Association meeting in Chicago yesterday that his efforts to cut costs and increase coverage couldn’t succeed without freeing doctors from the fear of lawsuits. While that may be what his audience needed to hear, the evidence that malpractice drives up health-care costs is “debatable,” said Robert Laszewski, an Alexandria, Virginia, consultant to health insurers and other companies.
“Medical malpractice dollars are a red herring,” Chandra said in a telephone interview. “No serious economist thinks that saving money in med mal is the way to improve productivity in the system. There’s so many other sources of inefficiency.”
Obama, appealing for doctors’ support for health-care legislation, said he would “explore a range of ideas” to reduce the effect of lawsuits, without giving specifics. While he opposes caps on jury malpractice awards, Obama said he recognized the legal threat spurs doctors to perform unnecessary tests and procedures — so-called defensive medicine.
‘Fear of Lawsuits’
Making U.S. care more efficient will be harder “if doctors feel like they are constantly looking over their shoulder for fear of lawsuits,” the president said.
July 14, 2009
Drinking one or two alcoholic beverages a day — but no more than that — appears to protect older adults from developing dementia, researchers reported here at the International Conference on Alzheimer’s Disease.
These “moderate drinkers” who are 75 years of age or older had a lower risk of developing dementia than people who had more than two drinks a day and those individuals who abstained from any alcohol completely, Dr. Sink and her colleagues found.
However, Dr. Sink said that despite the findings of the study she would not recommend that anyone who was a nondrinker begin to use alcohol to try to prevent dementia.
July 13, 2009
Nurse Owen Jay Murphy Jr. twisted the jaw of one patient until he screamed.
He picked up another one – an elderly, frail man – by the shoulders, slammed him against a mattress and barked, “I said, ‘Stay in bed.’ “
He ignored the alarms on vital-sign monitors in the emergency room, shouted at co-workers and once hurled a thirsty patient’s water jug against the wall, yelling, “How do you like your water now?” according to state records.
Murphy’s fellow nurses at Kaiser Permanente Riverside Medical Center finally pleaded with their bosses for help. “They were afraid of him,” a hospital spokesman said.
Under pressure, Murphy resigned in May 2005. Within days, Kaiser alerted California’s Board of Registered Nursing : This nurse is dangerous.
But the board didn’t stop Murphy from working elsewhere, nor did it take steps over the next two years to warn potential employers of the complaints against him. In the meantime, Murphy was accused of assaulting patients at two nearby hospitals, leading to convictions for battery and inflicting pain, board and court records show.
Even Murphy, who has since taken classes to curb his anger, was surprised the board didn’t step in earlier.
July 6, 2009
[…] So fundamental health reform — reform that would eliminate the insecurity about health coverage that looms so large for many Americans — is now within reach. The “centrist” senators, most of them Democrats, who have been holding up reform can no longer claim either that universal coverage is unaffordable or that it won’t work.
The only question now is whether a combination of persuasion from President Obama, pressure from health reform activists and, one hopes, senators’ own consciences will get the centrists on board — or at least get them to vote for cloture, so that diehard opponents of reform can’t block it with a filibuster.
This is a historic opportunity — arguably the best opportunity since 1947, when the A.M.A. killed Harry Truman’s health-care dreams. We’re right on the cusp. All it takes is a few more senators, and HELP will be on the way.
July 6, 2009
Acetaminophen leads the list of drugs implicated in liver damage requiring transplantation, although antiepileptics are more lethal, according to a new study.
Analysis of records from a transplant database found that patients with acetaminophen-induced injury were also more likely to be on life support than patients with liver failure caused by the next most common culprits, antituberculosis drugs, antiepileptics, and antibiotics (82%, versus 44% to 70%, P <0.0001), according to Ayse L. Mindikoglu, MD, of the University of Maryland in Baltimore and colleagues.
Patients whose liver failure was caused by acetaminophen also had a higher mean serum creatinine (3.21 mg/dL versus 1.31 to 1.86 mg/dL, P<0.0001), and a greater requirement for dialysis prior to transplantation (27% versus 3% to 10%, P<0.0001), the investigators reported in the July issue of Liver Transplantation.
Their report was issued just days after an FDA advisory panel recommended a “black box” warning for prescription combination drugs that contain acetaminophen. The panel also recommended that the maximum single adult dose be reduced from 1,000 mg to 650 mg, and that the maximum daily dose be reduced from its current level of 4,000 mg. (See FDA Panel Backs ‘Black Box’ Warning for Acetaminophen Prescription Combos)
As potentially hazardous to the liver as acetaminophen may be, the risk of death following liver transplantation was highest among patients whose liver injury was caused by antiepileptics, Dr. Mindikoglu found. In fact, the risk attributable to antiepileptics increased by a factor of 4.13 for patients under 18 and 1.03 for older patients.
The findings emerged from a retrospective cohort study of the United Network for Organ Sharing database, which includes almost all liver transplants in the U.S.
The records show that between October 1987 and December 2006, there were 661 liver transplantations for drug-induced injury.
A total of 567 were adults. The median age was 36, and the majority were female and white.
The implicated agents were:
* Acetaminophen in 265 (40%)
* Antituberculosis drugs in 50 (8%)
* Antiepileptics in 46 (7%)
* Antibiotics in 39 (6%)
Median survival for the whole cohort was 14.4 years, and one-year estimated survival probabilities were:
* Acetaminophen 76%
* Antituberculosis drugs 82%
* Antiepileptics 52%
* Antibiotics 82%
* Other drugs 79%
Comparison of outcomes according to age showed no overall significant differences in survival rates between pediatric and adult patients (P=0.56).
Two-year survival probabilities were 0.06 for children and .074 for adults.
But a marked difference was seen in survival following acute liver failure resulting from the use of antiepileptics, with a one-year survival of only 27% for children, compared with 75% for adults.
The high rate of death among pediatric patients with antiepileptic-induced liver failure may relate to valproic acid-induced hyperammonemic encephalopathy and carnitine depletion, the investigators suggested.
Patients whose liver failure related to antiepileptic use also had a greater frequency of retransplantation than the other groups (24% versus 4% to 9%).
Males were 1.4 times more likely to die than females, while a doubling of the serum creatinine increased mortality risk by 1.19. Patients on life support were 2.08 times more likely to die, the researchers reported.
Cox stepwise regression analysis found that independent pretransplant predictors of death were a requirement for life support, liver failure from antiepileptic drugs before age 18, and elevated serum creatinine.
The researchers proposed that those independent predictors could be used in a prognostic model for predicting post-transplant outcomes.
In an accompanying editorial, Paul H. Hayashi and Paul Watkins of the University of North Carolina wrote that this is the first study to propose a mathematical model to predict survival after transplantation for acute liver failure.
“Their attempt at modeling falls short of immediate usefulness, but the identification of poorer outcomes for children with antiepileptic [drug-induced acute liver failure] is intriguing and points out the need for more focused research,” the editorialists wrote.
They also observed that drug-induced liver failure, while a rare event, “has wide implications for all of us who take and prescribe medications,” and that in coming years significant advances can be expected in understanding of factors such as genetic predisposition.
The investigators noted that their study had limitations, “as expected from any retrospective database analysis,” such as the fact that they were unable to estimate numbers of patients who died before transplantation or spontaneously recovered.