Plasma Volume Estimates and Mortality

Measuring plasma volume is quite difficult and is an involved process. Therefore, equations have been developed that estimated plasma volume by some easily measured variables. One such equation is Straus formula. Using this formula, Marawan et al found that estimated plasma volume is not only related all-cause mortality but also to cardiovascular, cancer, and other-cause mortality.

These findings beg the question about the underlying mechanism of this association. It is difficult to say how this works except that perhaps one of the common final pathway of most diseases is to increase plasma volume.

Socioeconomic Status and Readmission Penalties

CMS will be including socioeconomic status when penalizing hospitals for excess readmissions within 30-days of discharge from hospital. the socioeconomic status will be determined by calculating the percentage of population seen at a hospital that are dual eligible (both Medicaid and Medicare).  See here for the details.

There is hope that this adjustment will allow hospitals that take care of very sick patients but also socioeconomically disadvantage populations will find a more even playing field when competing with hospitals that serve relatively wealthier populations.

It is a no brainer that patients with strong support systems, easy and quick access to their primary care provider, and high health literacy are less likely to be readmitted as compared to patients who lack these factors. Often, poor support system, poverty, lack of primary care access, and limited health literacy go hand in hand. These disadvantaged patients are most difficult to treat and are higher risk of disease-related and treatment-related complications.

Now Maddox et al has calculated which hospitals are likely to benefit and how large the benefit is going to be. They found that hospitals in the lowest quintile of dual enrollment (that is hospitals in the relatively wealthier neighborhoods) saw an increase of $12.3 million in penalties, while those in the highest quintile of dual enrollment (serving disadvantaged populations) saw a decrease of $22.4 million. Large hospitals, teaching hospitals, hospitals in the most disadvantaged neighborhoods, and those with the highest proportion of beneficiaries with disabilities were markedly more likely to see a reduction in penalties, as were hospitals in states with higher Medicaid eligibility cutoffs.

Shared Decision Making in Medicine

I was reading this ‘viewpoint’ in JAMA; an interesting read. I try to practice shared decision making as much as possible, perhaps more than what my patients would like.

However, I do feel that there is lack of data supporting shared decision making or ‘informed decision making’. I would perhaps define ‘informed decision making’ as decision making process in which patients are informed of their options and then given a recommendation by their treating physicians. Of course, patients have a right to say no to the recommended option, give reasons for refusing the recommended option, and then give their preferred option to the physicians.

Having said that, I am unaware of good data supporting any decision making strategy. There are, of course, tons of arguments supporting why shared decision making is good. But when, in medicine, we started depending on arguments without trying to develop evidence?

To develop evidence, first we have to define what is it that we want to achieve (an outcome). Some may argue that ‘shared decision making’ is in itself an outcome. I am not sure how this can be an outcome of choice. Perhaps a better outcome could be one that is patient-focused, such as mortality, morbidity, readmissions, quality of life etc. Things that matter are more meaningful. Or outcome that is physician-focused: such as number of law-suits by patients (or on behalf of patients). But there need to be reasonable outcome(s).

Then, we need to examine how shared-decision making affects those outcomes. My worry is that we are adding ‘must-do’ things in our workflow without determining their efficacy.

One way I look at the seriousness, or lack of it, by the proponents of a given ‘thought’ or ‘idea’ is their lack of desire to investigate their proposed remedy using scientific methods. We don’t accept a medicine, procedure, or treatment without strong evidence. Why we should accept other things using a lesser proof of evidence (unless we think it is not as important)?

One area where we find such a lack of seriousness in developing evidence is medical education itself. Even when we occasionally study a medical education intervention correctly, we find that our thinking was flawed. While we may claim that we understand the complexity of human behavior, we are often wrong. I doubt that we are right when it comes to shared decision making. When properly studied, I doubt we will find any effect on any important outcome.

Physician Burnout is Rising

Physicians have higher levels of burnout than the general US population. There are several proposed factors for this higher prevalence although none have been proven beyond doubt.

In addition to higher prevalence, the prevalence is increasing raising concerns for the health of some of the highly educated and skilled professionals in our society. A recent study found that the prevalence of burnout in a large academic medical center faculty increased from 40.6% to 45.6%. Both domains of burnout increased; exhaustion increased from 52.9% to 57.7% while depersonalization increased from 44.8% to 51.1%.

Other things that changed were that fewer physicians in 2017 felt that they had control over their schedules than in 2014 (71.6% vs. 64.3%), felt that they had could impact decision making that affects day to day practice (58.7% vs. 55.4%)  and were satisfied with their workload (55% vs. 50.5%).

Authors also validated a finding from prior studies that early-career physicians are more susceptible to burnout than mid-career physicians. However, they did not find a difference in burnout by gender or by race.

Readmission Rate and Insurance Type of the Patient

One of the programs instituted through the Affordable Care Act (ACA), also known as Obamacare, is the Hospital Readmissions Reduction Program (HRRP). This program focuses on the readmission of the patients within 30-days of discharge. Hospitals that perform worse than the national average are penalized up to 3% of their Medicare payments. While the program targets Medicare beneficiaries, it is likely that changes hospitals make to reduce readmissions will benefit all patients.

An article published in Health Affairs examines this question. Authors find that the readmission rates declined after the HRRP went into effect (not surprising as it has been shown by us and many others). In addition, they also report that readmissions declined for both Medicare and Medicaid patients. However, readmission rate of Medicaid patients remained higher than Medicare patients. Readmission rate was lowest for patients who had insurance throughout the study period and declined at a similar rate compared to others.

This study highlights an important but often neglected area when examining readmissions. Readmissions depend on three main factors:

1) Hospital Discharge Practices: These are factors that are under the control of the hospital (physicians and hospital employees). These include adequate discharge instructions, adequate hand-offs to the outpatient provider, adequate education about patient illness during hospitalization, making followup appointments, etc.

2) Patient factors: These includes the severity of the underlying illness of the patient. Some patients are far sicker and even when they are discharged from hospitals, they are just beyond the edge of the need for hospitalization. A small change in patient’s condition leads to a visit (and admission) back to the hospital.

3) Social support factors: These include support from family, friends, community, and other resources.

Of these three, very little attention has been paid to the third main factor, social support. Patients with private insurance are likely to have more resources and stronger support. On the other hand, patients on Medicaid are likely to be poor with an inadequate social support system. I believe that we will start hitting the wall with regard to the readmission rate reduction and the rate of decline in readmissions will start slowing down (if it is already not slowing). Ultimately, as a society, we will have to focus on the social support aspect of readmissions to keep patients healthy and out of the hospitals.