Tuesday, December 22, 2009

Health Care Problems in the USA

The following is from the New England Journal of Medicine, November 18, 2009.

Authors: Arthur L. Kellermann, M.D., Lawrence S. Lewin, M.B.A.


Adults who can’t get coverage through work, are too young for Medicare, and don’t qualify for Medicaid have only one option — individual health insurance. Consumer Reports describes the individual insurance market as a “nightmare” for consumers: “more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell affordable plans whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.”5 In recent years, several states have attempted to reform the individual health insurance market, with little success.

Coverage matters. On average, uninsured Americans get about half the preventive services and medical care that insured Americans receive. Studies have shown that uninsured people with cancer, heart disease, stroke, lung diseases, and other conditions are more likely to have poor health and to die prematurely than similar people with coverage. Existing safety-net services are insufficient to overcome the gap between those who have health insurance and those who do not.

The economic consequences of a lack of insurance are equally grim. If even one family member lacks coverage, the entire family is exposed to the financial burden of severe illness or injury. In 2009, 20% of uninsured adults used up all or most of their savings paying medical bills.

When many people lack insurance, everyone’s access to care is compromised. University of Pennsylvania economist Mark Pauly and colleagues have found that in communities with high proportions of people who are uninsured, insured people are more likely than those elsewhere to have difficulty obtaining needed care and to be dissatisfied with the care they receive.1 In such communities, emergency services are strained, access to trauma care is diminished, and a growing number of specialists are unwilling to take emergency department call.

If states cut their Medicaid programs when ARRA funding runs out, uncompensated care will increase sharply. The burden that this increase will impose on health care providers will be more than some can bear. If many safety-net clinics and hospitals close their doors, the patients these institutions serve will have nowhere else to go. When they end up in private hospital emergency departments and inpatient beds, it could trigger additional facility closures. Access to care will be diminished for the insured and uninsured alike.

Voting for the status quo may be politically tempting, but it won’t stop the steady erosion of coverage in the United States. The authors of the 2009 IOM report were blunt: “There is no evidence,” they wrote, “to suggest that the trends driving loss of insurance coverage will reverse without concerted action.”1 Six years ago, the IOM Committee on the Consequences of Uninsurance was equally direct.2 It recommended “that the President and Congress develop a strategy to achieve universal insurance coverage and establish a firm and explicit schedule to reach this goal by 2010.” That deadline is less than 2 months away.

Upstander


"...few of us feel as though we’re going to be perpetrators; and most of us hope we’re never going to be victims... most of us live in the space not between perpetrators and victims but between bystander and, potentially, ‘upstander,’ to coin a term. The question of how we relate to this history that goes on around us, or to matters of injustice."

Samantha Power
http://www.portsmouthpeacetreaty.org/powerforum2.cfm

Sunday, December 20, 2009

Tuesday, December 15, 2009

Not All Bad Behavior is Actionable....


Peoria's OSF/SFMC behavior towards their Haitian Hearts patients was again abysmal in 2009.

OSF/SFMC is denying medical care to two patients, Jenny and Henri, both who had heart surgery at OSF/SFMC ten years ago. They both need repeat heart surgery. Both are in Haiti and both receive medications and exams from Haitian Hearts year after year.

They both have hope to stay alive. But where is the hospital in Peoria that "turns no patients away"?

----------

A couple of days ago I received a comment on this blog.

The commenter was a local Peoria blogger who actually signed his name.

The fact that the blogger/commenter signed his name was unusual...most comments are made anonymously because people fear OSF.

What even made this more unusual was that the blogger/commenter wrote that OSF/SFMC was indeed sliding downwards with regard to quality of care. The blogger/commenter had been a patient at OSF/SFMC recently and wrote that OSF/SFMC ignored and laughed at his requests for pain meds.

Who knows if that was true or not, but that was the comment.

I was really surprised that this person actually signed their name.

However, by the next morning, the blogger/commenter had removed the portion of their comment which regarded OSF's poor care.

Thus, another blogger/commenter thought twice about going after OSF with their name attached. Fear of OSF had won out again.

In this blog I have documented how Keith Steffen, OSF's Administrator, told me that fear is a good thing among OSF employees. I clearly documented how he intimidated two of his nurses in his office at OSF.

I have spoken with many people in the Peoria community during the last decade who genuinely fear OSF and Mr. Steffen. Even a huge benefactor to OSF won't come out against Mr. Steffen in attempts to have him replaced because she fears for her own medical care at OSF/SFMC.

Is this the way a Catholic hospital (or ANY hospital) should act?

Numerous members of the Peoria community fear losing their job and their health insurance if they go after OSF. Our business boards are related and when you go after one business you go after all of them.

And to make matters even worse for OSF/SFMC, this year their legal counsel Douglass Marshall contacted the US Consulate in Haiti regarding a Haitian Hearts patient receiving medical care in Peoria. Many people knew about Marshall's action, but they did nothing.

For good reason they fear OSF.

The seven remaining OSF Sisters that live in the massive convent near the hospital don't walk with a bounce in their step. They know all this is happening, but have lost their mission and their spirit and their will to stop the fear engendered by OSF's secular leaders.

How sad for OSF and for Peorians.

Monday, December 14, 2009

Web Album of One Day in Haiti in 2009


Please go to this album and view as a slideshow.

This was July 1, 2009 in Cite Soleil.

Advanced Cardiac Drugs Don't Work Anyway....Or Do They?

The study copied below concluded that advanced cardiac life support drugs like epinephrine and atropine don't help the patient much during certain types of cardiac arrest.

But maybe they DO help if a cardiac arrest is from an asthma or anaphylactic arrest or a pediatric drowning. Who knows?

Does this mean that Advanced Medical Transport in Peoria will stop giving drugs like epinephrine at the scene of a cardiac arrest? Will AMT explain to the family that they are going to WITHHOLD drugs and quote statistics regarding Uncle George's small chance of being discharged from the hospital with good neurologic function?

Do most families want Uncle George dying in the backyard next to the lawnmower or in an intensive care unit two days later?

And, I digress slightly, but who will tell the people in Peoria who have lost loved ones during heart attacks, asthma attacks, drownings, etc., during the last 15 years that the Peoria Fire Department, until this summer, had NO advanced life support drugs to give them in the first place? Even though giving advanced life support drugs was and is the standard of care for advanced life support, the doctors that run EMS tried to reassure Peoria's City Council and Peorians that all was fine and good...until this summer when they changed it all.

Please see article below:

From Heartwire CME
Hold the Epi: No Advantage Seen With IV Drugs at Out-of-Hospital Cardiac Arrest CME
News Author: Steve Stiles
CME Author: Penny Murata, MD

December 4, 2009 — Facing off with longstanding policy and tradition, a large randomized trial found that giving intravenous (IV) drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge [1].

That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn't receive IV drugs during arrest, observe the authors, led by Dr Theresa M Olasveengen (Oslo University Hospital, Norway), in this week's Journal of the American Medical Association.

The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.

For now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation.

"These researchers present important and compelling data, which challenge the efficacy of one of the most common procedures in cardiac resuscitation: the administration of intravenous epinephrine," said Dr Bentley J Bobrow (Arizona Department of Health Services, Phoenix) in an email to heartwire . Bobrow, who wasn't involved in the study, is medical director of his state's Bureau of Emergency Medical Services & Trauma System.

"While epinephrine administration has been part of the guidelines for resuscitation for many years, there has been very little evidence supporting its benefit and some convincing evidence suggesting worse outcomes with higher doses of epinephrine," he remarked.

"The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation."

Olasveengen et al randomized 851 consecutive adults with nontraumatic out-of-hospital cardiac arrest to management according to advanced-cardiac-life-support guidelines with or without access to IV drug administration. In the no-IV-access group, those who achieved "return to spontaneous circulation" could receive IV drugs five minutes later, if indicated.

Those treated with access to IV drugs fared significantly better at first, but didn't outdo those managed without IV drug access for the primary end point of survival to hospital discharge.

Outcomes of Resuscitation in Out-of-Hospital Cardiac Arrest, With and Without IV Drug Access End point IV drugs (%), n=418 No IV drugs (%), n=433 OR (95% CI) p
Return of spontaneous circulation 40 25 1.99 (1.48-2.67) 0.001
Hospital admission 43 29 1.81 (1.36-2.40) 0.001
Survival to hospital discharge* 10.5 9.2 1.16 (0.74-1.82) 0.61


*Primary end point

Nor was there a significant difference for the primary end point in an analysis that controlled for response time, whether the arrest occurred in a public place or was witnessed, or whether ventricular fibrillation was the initial rhythm (odds ratio, 1.15; 95% CI, 0.69-1.91).

The quality of delivered cardiopulmonary resuscitation (including chest-compression rate, ventilation rate, and other factors), a prospectively defined secondary end point, was within guidelines and comparable in the two groups, Olasveengen et al report. So was the prevalence of therapeutic hypothermia as part of management, which exceeded 70%.

The trial has a number of limitations, the group notes, including the inability to blind emergency responders to the randomization and the involvement of a single emergency-response system. It also doesn't preclude the potential usefulness of other IV drug regimens. But, "at a minimum, our results indicate that clinical equipoise exists on the efficacy of intravenous drugs in the treatment of cardiac arrest and that more definitive trials could be ethically undertaken."

Olasveengen reports receiving fees for speaking from Medtronic and research support from Laerdal Medical. Of the coauthors, Dr Petter A Steen (Oslo University Hospital) reports being on the board of directors for Laerdal Medical and the Norwegian Air Ambulance Foundation (which provided partial funding for the study); and Dr Lars Wik (Oslo University Hospital) reports being on the medical advisory board of Physio-Control, consulting for Laerdal, Zoll, and Jolife, and being principle investigator of a Zoll-sponsored clinical trial.

Reference

1. Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA 2009; 302:2222-2229.

Clinical Context

Current cardiopulmonary resuscitation guidelines, as reported by the American Heart Association in the December 13, 2005, issue of Circulation, include IV drug administration. However, the benefits of epinephrine administration during advanced cardiac life support are not clear. In the July 2002 issue of Resuscitation, a retrospective study by Holmberg and colleagues found that the need for epinephrine after an out-of-hospital cardiac arrest was an independent predictor of poor outcome. Possible reasons include the effects of epinephrine or poor quality of cardiopulmonary resuscitation during the process of IV access and administration.

This prospective, randomized controlled trial assesses whether IV vs no IV drug administration during advanced cardiac life support after an out-of-hospital cardiac arrest in adults affects survival to hospital admission with return of spontaneous circulation (ROSC), survival to hospital discharge, 1 year survival, survival with favorable neurologic outcome, or quality of cardiopulmonary resuscitation.


Study Highlights

851 of 946 eligible adults older than 18 years with nontraumatic out-of-hospital cardiac arrest were randomly assigned to receive advanced cardiac life support with or without IV drug administration.

Exclusion criteria were cardiac arrest witnessed by ambulance team, resuscitation started or interrupted by physicians outside of ambulance team, or cardiac arrest resulting from asthma or anaphylactic shock.

Participants did not differ from nonparticipants in demographic data or outcomes.
418 patients were in the IV group.
433 patients were in the no-IV group, which received IV access and drugs (if indicated) 5 minutes after ROSC.
Mean age was 64 years.

IV vs no-IV group did not differ in sex, cardiac cause, location of cardiac arrest, bystander involvement, initial rhythm, presence of physician-staffed ambulance, response interval, or intubation.

Standard protocol included the 2000 International Guidelines (Circulation. 2000;102[8 Suppl]:I11-I11) modified by 3 minutes of cardiopulmonary resuscitation before first shock and between unsuccessful shocks for patients with ventricular fibrillation, defibrillators in manual mode, endotracheal intubation to secure airway, therapeutic hypothermia, and electrocardiogram transmission to cardiologist after ROSC.

Defibrillation attempts occurred more in the IV vs the no-IV group (47% vs 37%; odds ratio [OR], 1.16; 95% confidence interval [CI], 0.74 - 1.82).
Of patients who received defibrillation, more shocks were given to the IV vs the no-IV group (median, 3 vs 2; P = .008).

The primary outcome measure of survival to hospital discharge was similar for the IV vs the no-IV group (44 [10.5%] of 418 vs 40 [9.2%] of 433; OR, 1.16), even after adjusting for confounders (adjusted OR, 1.15).

Quality of cardiopulmonary resuscitation, assessed by hands-off ratio (hands-off time divided by total time without ROSC), compression rates, and ventilation rates, was adequate and similar for the IV vs the no-IV group.

Survival with favorable neurologic outcome (defined as good cerebral performance or moderate cerebral disability) was similar for the IV vs the no-IV group (9.8% vs 8.1%).

Short-term survival was greater in the IV vs the no-IV group:
ROSC (40% vs 25%; OR, 1.99; 95% CI, 1.48 - 2.67; P < .001)
Admission to hospital (43% vs 29%; OR, 1.81; 95% CI, 1.36 - 2.40; P < .001)
Admission to intensive care unit (30% vs 20%; OR, 1.67; 95% CI, 1.22 - 2.29; P = .002)

In patients with initial ventricular fibrillation or pulseless ventricular tachycardia, there were no outcome differences between groups.

In patients with initial nonshockable rhythms, the rates for ROSC, hospital admission, and intensive care unit admission were higher in the IV vs the no-IV group.

Multivariate analysis, adjusted for public location of cardiac arrest, response interval, and initial ventricular fibrillation, showed greater long-term survival if cardiac arrest showed initial ventricular fibrillation or pulseless ventricular tachycardia, was witnessed by bystander, or occurred in a public place.

Long-term survival odds decreased by 17% per minute of prolonged response interval (adjusted OR, 0.83).

Adjusted survival to intensive care unit was greater for the IV vs the no-IV group (adjusted OR, 1.78).

Cumulative survival rates for the IV vs the no-IV group include 7-day survival (14.6% vs 12.8%), 1-month survival (11.3% vs 8.8%), and 1-year survival (9.8% vs 8.4%).
Study limitations included inability to blind ambulance team to treatment group, cardiopulmonary resuscitation quality assessment in only 75% of cases, lack of reliable time line for drug administration, and lack of data on time of cardiac arrest.

Clinical Implications

In adults with an out-of-hospital cardiac arrest, IV vs no IV drug administration as part of advanced cardiac life support guidelines results in higher rates of short-term survival but does not affect survival to hospital discharge.

In adults with an out-of-hospital cardiac arrest, IV vs no IV drug administration as part of advanced cardiac life support guidelines does not affect 1-year survival duration, survival with favorable neurologic outcome, or quality of cardiopulmonary resuscitation.

Friday, December 11, 2009

The World's One Hope

 
"When a child steps out in front of a moving car, someone will snatch the child back to the sidewalk. It's not only a kind person who'd do that, not only the kind of person they honor with statues, and memorial plaques. Anyone would pull a child out of the path of the car. But here, many people have been run down, and many pass by, doing nothing. Is that because there are so many suffering people? Shouldn't there be more help when there's more suffering? There's less help. Even kind people walk past, doing nothing, and they're just as kind as they were before."

--from The World's One Hope, a poem fby Bertolt Brecht translated by Tony Kushner
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