Doctors “Bending” Ethical Norms to Best Serve Their Patients who can’t Bend their Joints

Rheumatic diseases, such as rheumatoid arthritis and lupus, are a common cause of disability. they affect all sectors of the population, diminish quality of life and have a significant social impact.

Yet, despite the benefits of early treatment and effective therapies, access to rheumatologic services may be difficult, involving long wait times, even difficulties finding providers.

C. Ronald MacKenzie, MD, a rheumatologist at Hospital for Special Surgery in New York City conducted a survey among rheumatologists entitled “Bending’ Ethical Norms to Serve Patients’ Interests:Tensions in Medical Professionalism,” to examine the medical, moral and ethical dilemmas doctors face when trying to do what’s best for their patients in the current health care environment.

The study was published in the October issue of the journal Arthritis and Rheumatism. “When people receive a diagnosis, the cost of effective treatment may render it unaffordable for many,” says Dr. MacKenzie. “While an optimal or fair system would mitigate these impediments to care, our survey of the American College of Rheumatology members suggests that this is often not the case. In fact, physicians report they frequently find themselves in situations of ethical conflict in an effort to best serve their patients.”

The survey consisted of 14 closed-ended and two open-ended questions and was sent to 5,500 members of the American College of Rheumatology.

Physicians reported ways in which they see themselves as ‘bending’ ethical standards and presented justifications for doing so. Examples included ‘embellishment’ of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain diagnostic tests and necessary medications and or physical therapy.

“The delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed.”

Medicine is not merely the scientifically based treatment and care of illness. It also involves ethical issues of right and wrong. In some cases, tough ethical dilemmas force doctors and other health care providers to make difficult decisions, all while upholding the Hippocratic oath to which all doctors are bound.

In today’s health care world, where the number of health care options can be great, medical ethics is of particular concern.Awareness of this problem and its consequences is only the first step in finding solutions to the challenges that physicians face.

Fixing the system in which physicians feel they have to ‘bend’ ethical norms and compromise ethical principles in order to provide the care their patients need, is clearly what’s so desperately needed.

 

 

 

 

 

 

Cutting Costs by Cutting Pills

According to some disturbing data released yesterday by the CDC, many US adults aren’t following doctor’s orders. And it’s not just the very young or very old, who, it could be claimed,  don’t know any better.

It turns out that adults under the retirement age are twice as likely to skip their prescribed medications in order to save money to save money.

And although spending on drugs is expected to increase an average of 6.6% a year from 2015 through 202, 20% of adults regardless of age, have asked their doctors for a lower cost treatment.

Americans spent $45 billion out-of-pocket on retail prescription drugs in 2011. But, “if you’re not insured or you face high co-payments, you’re going to stretch your prescriptions,” says Steve Morgan, an associate professor at the University of British Columbia’s School of Population and Public Health in Vancouver. “Even among insured populations, there is this invincibility mindset among the very young. Older people are more likely to adhere to chronic therapies over a longer period of time than younger.”

The study also found that 13% of those ages 18 – 64 reported not taking their medications as prescribed to reduce costs compared with 5.8% of those 65 and older.

Strategies that alter the way adults take their medications include skipping doses and consuming less than the prescribed amount. About 11% of those aged 18 – 64 also delayed filling a prescription compared with 4.4% of those 65 and older.

Uninsured adults were more likely to have tried to stretch their medications than those with Medicaid or private insurance.

But are such savings worth it? Failing to take medication as prescribed may actually increase costs to the U.S. health system, particularly if medication non-adherence results in increased hospitalizations, or complications of chronic diseases.

Anytime a patient chooses not to take drugs as prescribed, the pharmaceutical industry pharma loses sales. A recent study estimated that pharma loses $564 billion globally to non-adherence to drugs. Not surprisingly then, the industry is experimenting with reminders, to increase adherence. Nevertheless, a nudge from a text or a talking pill container might not inspire patients who are penny pinching.

I’d love to stay and chat, but I need to run to the pharmacy to refill my blood pressure meds that I ran out of several days ago!

When’s Your Time to Die?

What are your chances of dying in the next 10 years?

Obviously there are some activities that may increase your risk  such as driving drunk and active military duty in a war zone, but how about getting winded after walking several blocks or having trouble pushing a chair across the room

Turns out the latter might be just as dangerous as the former.

Researchers at the University of San Francisco VA Medical Center have recently come up with a “mortality index” to predict when a person may die.  Marisa Cruz and her colleagues have developed a list of 12 questions that can help predict chances of dying within 10 years for patients aged 50 and older.  The researchers created the index by analyzing data on almost 20,000 Americans over 50 who took part in a national health survey in 1998. They tracked the participants for 10 years. Nearly 6,000 participants died during that time.

While the test scores may satisfy people’s morbid curiosity, the researchers say their index wasn’t meant as guidance about how to alter your lifestyle.  Instead, it is mostly for use by doctors, to help them discuss the pros and cons of costly health screenings or medical procedures in patients who are unlikely to live 10 more years.

That said, we know that many of our readers are “simply dying” to take the test themselves – right now.

So without further ado…here’s how it works.

The 12 items on the mortality index are assigned points.  The fewer your total points the better odds of living.

• Men automatically get 2 points. In addition, men and women ages 60 to 64 get 1 point; ages 70 to 74 get 3 points; and 85 or over get 7 points.

• Two points each for: a current or previous cancer diagnosis, excluding minor skin cancers; lung disease limiting activity or requiring oxygen; congestive cardiac failure; smoking within the past 2 weeks; difficulty bathing; difficulty managing money because of health or memory problem; difficulty walking several blocks.

• One point each for: diabetes or high blood sugar; difficulty pushing large objects, such as a heavy chair; being thin or normal weight.

The highest, or worst, score is  26, which equates to  a 95% chance of dying within 10 years. To get that, you’d have to be a man at least 85 years old with all the above conditions.
For a score of zero, which correlates to a 3% chance of dying within 10 years, you’d have to be a woman of “normal weight” younger than 60 without any of those infirmities.

While it’s hardly surprising that a sick, older person would have a much higher chance of dying than someone younger why would being overweight be less risky than being of normal weight or slim?  One possible reason is that thinness in older age could be a sign of illness.

Dr. Stephan Fihn, a health quality measurement specialist with Veterans Affairs health services in Seattle, said the index seems valid and “methodologically sound.”
However, he adds that it is probably most accurate for the oldest patients, who don’t need a scientific crystal ball to figure out their days are numbered.

For fans of SRxA’s Word on Health, I’m pleased to report that my 10-year mortality index is zero. Let the blogging continue!

Testing, Testing… $, $$, $$$

If doctors knew the exact price of expensive medical tests would they order fewer of them?

That’s exactly what Johns Hopkins researchers wanted to know.

The answer has just been published in the Journal of the American College of Radiology, and it’s a resounding: No!.  According to the investigators, revealing the costs of MRIs and other imaging tests up front had no impact on the number of tests doctors ordered for their hospitalized patients.

“Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” says the study’s senior author, Daniel J. Brotman, M.D., director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

Some earlier studies have suggested that much of the expense of laboratory tests, medical imaging and prescription drugs is unknown or hidden from providers and patients at the time of ordering, leaving financial considerations largely out of the health care decision-making process and likely driving up costs. Other studies have shown that doctors ordered fewer laboratory tests in some cases when they were given the price up front.

But, imaging tests appear to be “a different animal.”

Although there are certain inherent disincentives, aside from cost, to ordering some major tests, such as the potential danger of radiation used, physicians also need to learn how to explain to patients why they may not need them.

For the six months of the study, Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched period from November 2009, to May  2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods.

And, when they compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no significant difference in ordering patterns.

Is this a good or a bad thing?

Certainly there are many instances when expensive tests are justified. When a key diagnosis is needed there are limited options for comparison shopping.  For example, when a patient appears to have had a sub-acute stroke, an MRI is needed regardless of cost.

That is not to say there aren’t times when physicians need to look more closely at whether too many imaging tests are being ordered. Do ventilated intensive care unit patients really need a daily chest X-ray to look for potential lung problems?  Especially when there is good medical evidence that outcomes aren’t compromised if X-rays are ordered only when the patient’s condition appears to be worsening.

“For too long, there has not been enough attention paid to the bottom line in health care,” Brotman says. This isn’t about rationing care to hold down costs, he says, but about choosing tests a little more wisely.

Even though price transparency didn’t influence the way physicians ordered imaging tests in this study, financial considerations may play a role in other circumstances if tied to clinical evidence.

If you show a provider that he or she is ordering four times as many CT scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better.

“Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Brotman says. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

Seems logical to us.

Vital Signs of Health

Roll up your sleeve for the blood pressure cuff. Stick out your wrist for the pulse-taking. Lift your tongue for the thermometer.Report how many minutes you are active or getting exercise.

Wait, what?

If the last item isn’t part of the usual drill at your doctor’s office, a movement is afoot to change that. One recent national survey indicated only a third of Americans said their doctors asked about or prescribed physical activity.

Kaiser Permanente, one of the nation’s largest nonprofit health insurance plans, made a big push a few years ago to get its southern California doctors to ask patients about exercise. Since then, Kaiser has expanded the program across California and to several other states. Now almost 9 million patients are asked at every visit. And the trend is spreading among other medical systems.

Here’s how it works: During any routine check of vital signs, a nurse or medical assistant asks how many days a week the patient exercises and for how long. The number of minutes per week is posted along with other vitals at the top the medical chart. So it’s among the first things the doctor sees.

“All we ask our physicians to do is to make a comment on it, like, ‘Hey, good job,’ or ‘I noticed today that your blood pressure is too high and you’re not doing any exercise. There’s a connection there. We really need to start you walking 30 minutes a day,'” says Dr. Robert Sallis, the Kaiser family doctor who initially hatched the vital sign idea.

A study looking at the first year of Kaiser’s effort showed more than a third of patients said they never exercise.  Many patients were not aware that physical inactivity is riskier than high blood pressure, obesity and other health risks people know they should avoid. Few know that those who routinely exercise live longer than others, even if they’re overweight.

Take Zendi Solano, 34, who works for Kaiser as a research assistant in Pasadena, CA. She always knew exercise was a good thing, but until about a year ago, when her Kaiser doctor started routinely measuring it, she “really didn’t take it seriously.”  She was obese, and had elevated blood sugar. She sometimes did push-ups and other strength training but not anything very sustained or strenuous.

So she decided to take up running and after a couple of months she was doing three miles. Then she began training for a half marathon, formed a running club with co-workers and started eating smaller portions and buying more fruits and vegetables.  She is still overweight but has lost 30 pounds and her blood sugar is normal. Her doctor praised the improvement at her last physical in June and Solano says the routine exercise checks are “a great reminder.”

Kaiser began the program after 2008 government guidelines recommended at least 2 1/2 hours of moderately vigorous exercise each week. That includes brisk walking, cycling, lawn-mowing — anything that gets you breathing a little harder than normal for at least 10 minutes at a time.

Now other health systems are following suite. Dr. Elizabeth Joy of Salt Lake City has created a nearly identical program and she expects 300 physicians in her Intermountain Healthcare network to be involved early this year.  NorthShore University HealthSystem in plans to start an exercise vital sign program this month, eventually involving about 200 primary care doctors.

All of which is good news. Figuring out how to get people to be more active could have a big effect in reducing medical costs and improving health. Here at SRxA’s Word on Health we’ll be working on our Exercise Minutes.  Will You?

Putting the squeeze on anti-cancer drugs?

For years, doctors have warned patients that grapefruit juice can cause overdoses when combined with anything from cholesterol medication to antihistamines. Now, researchers at the University of Chicago medicine have discovered that drinking one glass of grapefruit juice a day can actually reduce the dosage, cost and side effects of certain drugs, including those used to treat cancer.

Doctors were interested in studying the sirolimus, a drug approved to prevent rejection after kidney transplant, on patients with incurable cancer. Knowing that only 14% of the drug is absorbed into the blood stream, and that higher doses can cause nausea and diarrhea, they went about searching for a supplement that would boost sirolimus absorption.

That was when lead researcher Dr. Ezra Cohen remembered grapefruit juice can increase blood levels of certain drugs.  “We saw that not as a problem but as an opportunity to enhance the pharmacology to not only sirolimus but to a wide range of drugs.”

Grapefruit juice’s potential pharmaceutical prowess stems from its ability to inhibit enzymes in the intestine that break down certain drugs. The effect begins within a few hours of drinking it and  wears off gradually over a few days.

So Cohen and his team gave some patients grapefruit juice to see if they could get more sirolimus into their bloodstreams. At first, Cohen gave his patients grapefruit juice, but nothing happened. That was when the Florida Department of Citrus got wind of the study and offered to test a sample of the grapefruit juice Cohen’s team was using.

“Dr. Cohen didn’t realize that the compound that enhances drug absorption can be degraded kind of drastically,” said Dan King PhD, the director of scientific research at the department. “This juice he was using didn’t have a whole lot of this compound present.”

The compound is furanocoumarin, and it works by inhibiting enzymes in the intestine that would otherwise limit drug absorption. Cohen’s juice had almost none because it was canned and stored in the non-refrigerated section of the grocery store.  Such juice is heated to temperatures that degrade the furanocoumarin.

Having identified the problem, the Department of Citrus supplied “potent” grapefruit juice for the rest of the study. It worked, increasing sirolimus levels by an incredible 350% and lowering the necessary doses from 90 mg per week to between 25 and 35 mg per week.

“Sure enough, what they sent was very potent,” Cohen said. “It allowed us to reduce the dose of sirolimus dramatically.”  It could also reduce the cost of cancer treatments which are problematic for a lot of patients.

Unfortunately, the study didn’t show that the sirolimus-grapefruit combo was completely effective against cancer. None of the 138 patients in the study had a complete response, but about 30% achieved stable disease, meaning a period when their cancers did not advance. And one patient in the grapefruit juice group experienced significant tumor shrinkage that lasted for more than three years.

Jerry Avorn MD, chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital in Boston, did not work with researchers on the study, but said he is excited about the results.  “It’s important not to see this as a new cure for cancer, but rather, it’s a very interesting way of using a known food-drug interaction as a means of getting better drug levels into cancer patients.”

SRxA’s Word on Health believes this is the first cancer study to harness a grapefruit-drug interaction rather than warn against it. We look forward to more.

i-Nhaler i-Mprovement?

Asthma is one of the world’s most common chronic diseases, affecting some 300 million people and almost 5 percent of the world’s population. It’s also the 5th most costly condition in the US  – an estimated at $56 billion annually. But as we’ve reported here previously, a significant number of people with asthma either don’t use their asthma medications or use them incorrectly.

Improving asthma control is known to reduce the cost of treating asthma by eliminating unnecessary hospitalizations, ED visits, and office visits. The additional cost of an uncontrolled asthma patient compared to a controlled asthma patient is estimated at $3,000-$4,000  per patient annually.

So, we were interested to learn last week that the FDA approved a sensorized asthma inhaler that can track usage and transmit the data to a smartphone and the web. The manufacturer – Asthmapolis will begin to market the asthma sensor and both English and Spanish language versions of the companion software in the US very soon.

“Our mission is to make it easier for patients and their physicians to do a better job of managing asthma with less effort than traditionally required.” said David Van Sickle, co-founder and CEO of Asthmapolis.

The small and lightweight device attaches to the end of most inhalers, and the app tracks the time and location of each medication discharge and reminds patients to use it if they forget.

In clinical studies of the Asthmapolis system, uncontrolled asthma declined by 50%, and more than 70% of patients improved their level of control.  In addition it can identify trends in a patients asthma triggers and symptoms over time and provide patients with personalized education on how to improve their asthma.

Not only will the device talk directly to the patients, physicians and other health care providers will be able to identify, in near-real-time, patients with uncontrolled disease and attend to them before they suffer a severe exacerbation.

“Despite all we know about asthma and how to treat it, the majority of patients still do not have the disease under control, and traditional approaches to self-management have been time-consuming and complicated,” said Inger Couture, chief regulatory officer of Asthmapolis. “The Asthmapolis technology makes it much easier to track symptoms and use of metered dose inhalers, allowing patients, their families and their doctors to gain a valuable new perspective on the disease.”

And that can only be a good thing.

Whoa, whoa, whoa, whoa – Washing at the Handwash!

A few years ago the Centers for Disease Control and Prevention (CDC) estimated that about 1.7 million patients get a hospital acquired infection each year. Of these, 99,000 die. More recently they estimated that infections develop in about 1 to 3 out of every 100 patients who have surgery.

Separately, a new study just presented at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC) found that preventing further complications in patients who develop infections after hip or knee replacement surgery could save the U.S. health-care system as much as $65 million a year.

Hardly surprising then, that the pressure is mounting to reduce hospital-acquired infections. Some of this is being driven by Medicare who has started reducing  payments for hospital readmissions.

Infection-prevention specialists are now focusing on new practices and products to minimize patient exposure from the environment as well as from medical procedures and surgical instruments.

For example, Baycrest Geriatric Healthcare System in Ontario, were able to reduce the rate of transmission for the staph infection MRSA by 82% over a 33-month period by bathing patients daily with germ-killing cloths.   The cloths are presoaked with a powerful antimicrobial agent – chlorhexidine gluconate, which reduces organisms on a patient’s skin and leaves a residue that lasts up to six hours.  Baycrest, also screens all patients on admission to determine if they are colonized with MRSA on the skin, indicating the organism is present on the body but not yet causing an infection.

Many other innovative  infection-prevention ideas were suggested at the APIC “film festival”, which featured short videos including music, drama, dance, humor and animation to promote adherence to best practices.

SRxA’s Word on Health particularly liked the winning video “Scrub-A-Dub Dub”, which features Jerry Herman a former patient from the All Children’s Hospital in St. Petersburg, FL, along with his twin brother, Josie.

The 10-year-old, who spent several months in the ICU, almost totally paralyzed by Guillain-Barré Syndrome, reinforces proper hand-washing technique among staff, patients and families.

Can a hip-hop song improve health?  We think maybe it can.

Prescriptions, Physicians, Patients and Payers: Let the battle commence!

Last week the FDA announced that it wants to remove obstacles to America’s most commonly used drug treatments.  If the Agency gets its way, some drugs used to control chronic conditions, such as high cholesterol, diabetes and asthma may soon be available without prescription.  But in doing so, they have reopened a  big can of worms. One that brings into question the very nature of health reforms, preventative medicine and improved access to healthcare.

Here’s the proposal: The FDA would create a new class of “safe use” drugs. While consumers would not need a prescription, they would still need to get clearance from a pharmacist or from specially designed websites to purchase them.

Battle lines are being drawn! With physicians on one side, and patients, pharmacists, pharma and payers on the other.

Doctors are most definitely not thrilled by the idea. Removing the prescription requirement for an inhaler refill, for example, doctors fear they would be taken out of the loop on everyday care decisions.

Insurers, on the other hand are embracing the move. They recognize that they could save big bucks if physician visits weren’t required for run-of-the-mill complaints and ongoing medication monitoring. They might even save on the costs of the drugs themselves because, depending upon how they’re classified, most health plans don’t pay for over-the-counter treatments.

Pharmacists see it as validation of their expertise and pivotal role in primary healthcare and the pharmaceutical industry, who has repeatedly asked for permission to sell such drugs over-the-counter, must surely be cautiously optimistic.

Even normally conservative regulators are supporting the move. “Greater over-the-counter and behind-the-counter access will lower costs and make healthcare more accessible to consumers,” former FDA commissioner Scott Gottlieb said via Twitter. “It’s a good idea, long overdue.”

Even so, the FDA will have a fight on its hands as it moves to turn its proposal into reality. The American Medical Association lambasted the idea in USA Today, saying that patients need guidance from doctors. The doctors’ association also points out that giving patients more control could complicate coordinating care, such as, tracking all the drugs a patient uses to prevent interactions.

But, as The Washington Post points out, FDA sees the doctor’s visit as a hindrance to care; some patients don’t seek treatment if they have to see a physician first. “Obviously, it’s much easier for you to go to your drug store and pick up an item than it is to make an appointment, take a prescription, drop it off and get it filled,” says Nancy Chockley, president of the National Institute for Health Care Management.

About 20% of prescriptions written in the United States currently go unfilled. Removing obstacles that keep Americans from managing their own health care is, according to one patient, namely me, a good thing.

The FDA contends, and I agree, that some consumers may not even go as far as getting a prescription because of the “cost and time required to visit a health-care practitioner.  Earlier this month, I stood in line at my local pharmacy for thirty minutes to pick up a refill prescription for blood pressure meds. On reaching the end of the line I was told that there was no prescription. The pharmacist called my doctor and the lack of prescription was confirmed. I called my doctor and was told I would need to make an appointment to have the prescription renewed. I pointed out that I had done that one month earlier and that nothing had changed regarding my health. I was then informed that it was a new policy to issue prescriptions on a month-by-month basis rather than provide automatic refills. Even when I pointed out that I have a chronic condition that I’m doing my best to manage and part of that management is the medicine I have been taking for years, they wouldn’t sway. No doctors visit, no prescription.  And the kicker, I couldn’t get an appointment to see my doctor for a week…meaning, I had to go 7 days without blood pressure meds, all so my doctor could better manage my care!

Practicing medication adherence is very hard when your doctor won’t give you medication…and leaves me wondering if this policy change had more to do with revenue generation than improving chronic disease management.

My personal experience aside, at the heart of this discussion is a fundamental disagreement over what role doctors play in managing patient care. The FDA proposal views a trip to the physician as a hindrance to care, whereas doctors see that visit as crucial, especially as chronic conditions become increasingly prevalent.

The FDA proposal is still in formative stages, meaning there’s still a lot of space for this debate to evolve. Where the discussion heads on this particular issue could end up guiding health policy on what role doctors play in managing patient care – and, at what point, the patient takes charge.

I, for one, can’t wait to see how it plays out, assuming of course that I’m not dead from uncontrolled hypertension!

Drugs That Can Land You in the Emergency Room

It’s midnight at the fire station and a call goes out for a patient who has overdosed. In addition to an ambulance and medic unit, police are dispatched.  As we stage for the police, to ensure that the scene is safe, we speculate as to what we’re going to encounter. Will the patient be conscious? What sort of emotional distress has driven them to this? Is it a serious attempt or a cry for help?  Will there be weapons?

As we mentally run through all types of scenarios, it’s doubtful that many of us have considered that our patient will be an 82 year old great grandmother armed with nothing more than her reading glasses and the remote control.

But increasingly that’s what we might find.  As Americans live longer, we have an increasingly frail population suffering from a greater number of chronic conditions, taking more medications than ever before. Among adults 65 years of age or older, 40% take 5 – 9 medications and 18% take 10 or more.

This type of polypharmacy is associated with an increased risk of adverse events. Older adults are nearly seven times as likely as younger persons to have adverse drug events that require hospitalization.

According to a recent article in the New England Journal of Medicine blood thinners and diabetes drugs cause most of the unintentional overdoses that lead to emergency hospitalization in older patients.

Researchers reviewed the records of 100,000 hospitalization events due to major drug side effects in people aged 65 and above from a representative sample of 58 hospitals.  Almost half, (48%) of adverse drug event (ADE)-related hospitalizations occurred in patients older than 80.

The drugs they looked at included prescription and over-the-counter medications, vaccines, and dietary supplements.

Adverse events were categorized as allergic reactions, undesirable pharmacologic or idiosyncratic effects at recommended doses, or unintentional overdoses.  Other effects included problems due to medication-delivery methods (e.g., choking) and vaccine reactions. Visits for intentional self-harm, drug abuse, therapeutic failures, and drug withdrawal were excluded.

Shockingly, just four medications accounted for more than two-thirds of emergency hospitalizations:

• warfarin (a blood thinner to prevent clots) – 33%
• oral antiplatelet agents (for heart attack prevention) – 13.3%
• insulin (for diabetes) – 13.9%
• oral hypoglycemic agents (for diabetes) -10.7%

Given that emergency hospitalizations caused by ADEs result in significant morbidity and enormous costs it’s not surprising that decreasing harm to patients and reducing costs by preventing re hospitalizations is a goal of the $1 billion federal initiative Partnership for Patients.

Achieving a 20% reduction by the end of 2013 may sound ambitious, but in fact there are a number of simple steps that we can take.

1. Make sure that everyone taking medications has an up-to-date list, including all prescribed drugs as well as vitamins, herbs, and OTC medicines. Copies of the list should be kept in their wallet and should be shared with all doctors they see so that the potential for drug interactions can be assessed and avoided.
2. Alert your loved ones that blood thinners and diabetic medicines account for 50% of hospitalizations due to ADEs. Blood thinners and diabetes medications should be regularly monitored by the primary care physician.
3. Encouraging medication compliance can lengthen a person’s lifespan. Too many times patients stop their medications due to a comment made by a well-meaning friend who has  read something on the Internet. Often the doctor is not informed and the patient may not understand the positive effects of the medication or the dangers of stopping them suddenly.

These small measures may not only save the life of your elderly loved-ones, but they may also  reduce your Word on Health bloggers’ middle of the night 911 dispatches.