Are Young Women Getting Unnecessary Medical Care?

The annual pelvic examination in otherwise healthy women is considered part of the well-woman visit. Similarly, Pap-smear is performed for cervical cancer screening among sexually active women. Screening for cervical cancer is not recommended for women younger than 21 years, a consensus reached by the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and American Cancer Society. The general recommendation is against performing pelvic examinations in asymptomatic, nonpregnant women younger than 21 years. However, young women are still undergoing such exams during their physical examinations.

How big is the problem of these unnecessary exams? Qin et al has recently published their findings using the National Survey of Family Growth. They estimated that between 2011 and 2017, an estimated 2.6 million women aged 15 to 20 years in the United States (22.9%) received a pelvic examination in the past year, and 54.4% of these examinations were potentially unnecessary. Further, an estimated 2.2 million young women (19.2%) received a Pap-smear test in the past year, and 71.9% of these tests were potentially unnecessary.

Tele-Health and Liver Transplant

Liver transplantation is the only treatment that increases survival times of patients with decompensated cirrhosis. Patients who live further away from a transplant center are disadvantaged. Health care delivery via telehealth is an effective way to remotely manage patients with decompensated cirrhosis. Authors investigated the effects of telehealth on the liver transplant evaluation process.

Using regression models, authors evaluated the differential effects of telehealth vs. usual care on placement on the liver transplant waitlist. We also investigated the effects of telehealth on time from referral to initial evaluation by a transplant hepatologist, liver transplantation, and mortality.

Authors found that the use of telehealth was associated with a substantial reduction in time from referral to initial evaluation by a hepatologist and placement on the liver transplant waitlist-especially for patients with low MELD scores, with no changes in time to transplantation or pre-transplant mortality.

Hospital Readmission Penalty Might be Increasing Mortality

Hospital Readmission Reduction Program and association penalties for higher than average/expected readmissions have resulted in a significant decrease in 30-day readmissions after hospital discharge. This also appears to have saved money to the CMS. When looking at the readmissions only, this programs appears to be a resounding success. However, its unintended consequences are becoming clear only now.

Using a national database of almost all hospitals, this study found that hospitals that were able to decrease readmission rates for patients with acute exacerbation of COPD, also had an increase in mortality for such patients within 30-days after discharge. While the underlying mechanisms are open for speculation, this association needs to be taken seriously and possibility of a casual relationship needs to be explored.

Stacked ICU Admissions and Mortality

This interesting study shows that when ICU admissions are stacked, that is two or more admissions come too close to each other, there is an increased risk of patient mortality, longer hospital stay, and higher odds of nursing home discharge.

Investigators enrolled 13,234 consecutive ICU admissions of which 1/4rth had an elapsed time since the last admission (ETLA) of < 55 min. Stacked admissions had on average, a higher unadjusted [1.16 (95% CI 1–1.35, P = 0.05)] and adjusted [1.23 (95% CI 1.04–1.44, P = 0.01)] odds ratio of ICU death, higher unadjusted [1.11 (95% CI 0.99–1.24, P = 0.06)] and adjusted [1.20 (95% 1.05–1.35, P = 0.004)]  odds ratio of hospital death, and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84–0.99, P = 0.04).

Anti-Mullerian Hormone in Men

Anti-Müllerian hormone (AMH) is a Sertoli cell-secreted protein that plays a major role in the development of internal male genitalia during embryonic life. Around the 7th week of gestation, AMH causes regression of the Mullerian duct and hence it is also known as Müllerian-inhibiting substance (MIS). Persistent Mullerian duct leads to formation of female internal sex organs. During adult life, AMH continues to be produced by the Sertoli cells in the testis in men although its functional relevance remains unclear.

In 2016, an very strong association of AMH with all-cause mortality was reported in men.

“In unadjusted analysis, each unit increase in serum anti-mullerian hormone level was associated with a 13 % lower risk of death (HR = 0.87; 95 %CI = 0.83-0.92). In multivariable models, the inverse association between serum anti-mullerian hormone levels and mortality remained significant (HR = 0.94; 95 %CI = 0.90-0.98) and was independent of confounding variables. Similarly, individuals in the highest quartile had significantly lower risk of death as compared to individuals in the lowest quartile (unadjusted HR = 0.13, 95 %CI = 0.07-0.25; adjusted HR = 0.36, 95 %CI = 0.16-0.81).”

While the study showed an association the underlying mechanistic pathways remained unclear.

Recently, AMH has been shown to be associated with serum C-reactive protein (CRP) levels in men raising the possibility that the underlying mechanism may include modulation of inflammatory response. It is a potentially an exciting area of research and new discoveries in future may highlight important relationships between AMH and health, morbidity, and mortality in humans.

Soft Drink Consumption and Mortality

In this population-based cohort study of 451,743 individuals from 10 countries in Europe, greater consumption of total, sugar-sweetened, and artificially sweetened soft drinks was associated with a higher risk of all-cause mortality.

1. 17% higher all-cause mortality was found among participants who consumed 2 or more glasses per day (vs consumers of <1 glass per month) of total soft drinks (hazard ratio [HR], 1.17; 95% CI, 1.11-1.22; P < .001),

2. 8% higher mortality in participants who consumed sugar-sweetened soft drinks (HR, 1.08; 95% CI, 1.01-1.16; P = .004), and

3. 26% higher mortality in participants who drank artificially sweetened soft drinks (HR, 1.26; 95% CI, 1.16-1.35; P < .001).

Consumption of artificially sweetened soft drinks was positively associated with deaths from circulatory diseases, and sugar-sweetened soft drinks were associated with deaths from digestive diseases.

Hospital Visits After Discharge in Readmission Reduction Program Era

This study raises interesting questions about the effectiveness of the Hospital Readmission Reduction Program. While readmissions are going down, the hospital ED visits and observation admits are going up. Are hospitals gaming the system?

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.

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.

Readmissions and Mortality–Any Difference by Race?

Since the introduction of Hospital Readmission Reduction Program by the CMS, there has been a significant decrease in readmissions for all targetted diseases. However, studies have raised concern that although readmissions are decreasing, there may be an increase in mortality.

A recent study showed that there is no difference in mortality between white and black patients. Authors used interrupted time-series analysis. I enjoyed statistical modelling but wonder if the within-hospital and between hosptial effects were properly accounted for. In other words, the assumption in their modeling is that both effects are the same (unlikely to be true). It is possible that the within and between effects are different and may shed a better light on what is happening at individual hospital level and what is happening across hospitals. Having said that, it is an interesting study with important implications.

Social risk factors adjustment for readmission penalties

I have shown, in my previous work, that social risk factors affect hospital performance. CMS, at th eurging of Congress, will be including including social risk factors in their patient risk models. Here is an interesting paper that examined retrospectively the effect of adjustment for social risk factors on readmission penalties and found that the penalties will drop by almost half for safety-net hospitals. I am certain that these adjustment will bring more fairness in hospital comparisons and will decrease the amount of penalty these safety-net hospitals have to face. 

Genistein, a Phytoestrogen, and Mortality

Several studies in medical literature and countless lay-media articles promote the benefits of phytoestrogens. In this large study, using data from NHANES, Marcelo and colleagues showed that that high levels of genistein in urine are associated with lower mortality. In particular, it decreases mortality from all causes.

Apixaban in ESRD and Atrial Fibrillation

Patients with ESRD (end-stage renal disease) are usually prescribed coumadin when they need anticoagulation; the reason being that we know very little (or not at all) about the effect of new oral anticoagulants in patients with ESRD.

In this study, Siontis et al performed a retrospective cohort study of Medicare beneficiaries with ESRD and atrial fibrillation, the later an indication for anticoagulation. Outcomes were compared between patients who were treated with apixaban versus patients who were treated with warfarin. Authors examined the survival difference between the two groups for stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death using Kaplan–Meier analyses and hazard ratios (HRs) and 95% CIs were obtained using Cox regression analyses.

Authors found that there was no difference in stroke and systemic embolism between the two groups. However, the group taking apixaban had 28% lower risk of major bleed.

While this is retrospective data, and clinical trial data is lacking, this study will support the use of new oral anticoagulants in ESRD patients.

Vitamin D and Cardiorespiratory Fitness

Here is a study just published showing relationship between cardiorespiratory fitness and vitamin D levels. The study adjusted for various confounders and the relationship was independent of these confounders. The study is cross-sectional and hence the direction of causal effect is difficult to determine. That is, whether greater cardiorespiratory fitness is associated with more time spent outside and hence more sunlight exposure and vitamin D formation or whether vitamin D, through its effects on muscles, nerves, bones, results in higher cardiorespiratory fitness

Aspirin and Body Weight

Low dose aspirin has been shown to reduce cardiovascular events but the observed effect may vary by weight. In fact, in one of our studies, we have shown that not only obese individuals had greater baseline platelet reactivity, they also had greater residual platelet reactivity after low-dose aspirin therapy. Comparing obese and nonobese individuals after aspirin therapy, results for aggregometry to collagen were 6.7 vs 6.1 ohms, P=.008; aggregometry to adenosine diphosphate were 13.1 vs 11.8 ohms,P<.0001; aggregometry to arachidonic acid (AA) were 4.9% vs 8.3% nonzero aggregation, P=.002; urinary excretion of 11-dehydro-thromboxane B2 (Tx-M) were 4.9% vs 8.3% nonzero aggregation, P=.002; and aspirin resistance were 26.% vs 20.5%, P=.002; respectively.

Now an individual-patient meta-analysis of primary prevention randomized controlled trials with low-dose aspirin have shown that clinical outcomes are also different in patients with weight>70Kg than in patients with weight<70Kg. On the other hand, when a higher dose of aspirin was examined, individuals with weight>70Kg obtained clinical benefits. Clinical benefits were not limited to cardiovascular outcomes but also included colorectal outcomes.

An obvious implication of such studies is that individuals with weight>70Kg should take perhaps more than one baby aspirin to receive benefit from aspirin.

Struggling Healthcare Organizations

A systematic review identified five characteristics of healthcare organizations that are struggling to improve quality.

1.  Poor organizational culture: Such as limited ownership, not collaborative, hierarchical, with disconnected leadership

2. Inadequate infrastructure: Limited quality improvement, staffing, information technology or resources

3. Lack of a cohesive mission: Mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity

4. System shocks: Events such as leadership turnover, new electronic health record system or organizational scandals that detract from daily operations

5. Dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Physician Competition Effects

An interesting study examined the impact of competition among cardiologists on service provision and patients' health outcomes in the United States. Authors found that cardiologists in more concentrated markets perform more diagnostic procedures. On the other hand, higher concentration result in fewer readmissions but has no effect on mortality.

Medical Bill Collections Decrease with Patient’s Age

An interesting study that finds that the average size of medical debt decreased nearly 40 percent from when patient was twenty-seven old to when sixty-four years old. Authors thought that this was with an increase in health insurance coverage and incomes.

Machine Learning Predicts Clinical Deterioration

Edelson and her colleagues trained a gradient boosted machine model on a dataset of almost 300K patients and were able to predict clinical deterioration better than the modified early warning (MEWS) system. Here is the link for the abstract that was presented at ATS 2018.

The simplicity of the tool which uses only age, heart rate, and respiratory is really impressive. Interestingly, respiratory rate is often the least accurately measured vital sign in the hospitals despite its simplicity. A more accurate measurement of respiratory rate can potentially help better predictive models to predict clinical worsening in a patient’s condition. Better prediction can not only help to patients by focusing on the cause of clinical worsening but will also help to more optimally utilize resources within the hospital.