An Ounce of Prevention

It has been predicted that the 2017-2018 influenza season may be severe.  It is starting early – having shown up in Southern California earlier than usual.  It causes or is a part of the cause of death in thousands of people in the US every year – mostly small children/ babies and the elderly.  The Centers for Disease Control and Prevention (CDC) has published guidance for preventing seasonal influenza in the workplace.

  • Promote influenza vaccine: “The single best way to protect against the flu is to get vaccinated each year.”   There are several types of vaccine that can be used depending on your particular health situation.  It is recommended for everyone 6 months and older.   Otherwise there are few people for whom the vaccine is not appropriate.  Vaccination during preganancy can help protect your newborn who is particularly at risk if the baby catches influenza.
    • Unfortunately, as the vaccines are prepared early in the year in anticipation of the major predicted strains of influenza in the fall, this year the vaccine was off the target from the prevalent strain causing influenza this year. However, protection against the 2 or 3 other strains involved in causing influenza remains.   It is still highly recommended.  I got mine – even during the fires!
    • The influenza vaccine is given at a time of the year when common colds show up in the population (kids back in school) – so many people have said they thought that the vaccination gave them the illness. THIS DOES NOT HAPPEN.
  • Hygiene
    • We have become familiar with cover your cough (either with your elbow or a tissue) and dispose of the tissue properly – stand away – it doesn’t take much distance to reduce exposure.
    • Wash your hands – transmission from hands can be prevented by washing. I do frequently during the day and when I arrive home from work.  Don’t be nuts about it but have common sense.
  • Know the signs and symptoms of influenza – influenza is NOT the common cold (people do come to work with colds – kinda unavoidable and a nuisance).  I consider influenza with the following symptoms that can often develop quickly:
    • Fever – almost always (or chills)
    • Cough – influenza is a respiratory illness
    • Body aches – yeah, this is part of the misery – ache all over
    • Headache – another typical part of the misery.

So you can see how influenza is different from the run of the mill cold or stomach ailment.  You can have sniffles, sore throat, stomach complaints, fatigue too, but I pay attention to the top four.

  • If you think you have influenza – GO HOME – STAY HOME– WATCH NETFLIX! (although you may want only to sleep) – Check in with your health care provider if you are at high risk or take a turn for the worse.   Don’t be a part of the spread of influenza in the workplace.

I practice these measures for five reasons

  • I don’t want to get sick – influenza – not the common cold – is miserable
  • I don’t want to use my valuable PTO time being ill! (hmm vacation or home feeling like I’ve been run over)
  • I don’t want to bring it home to my family (what a way to spoil the holidays and new year – and they will get mad at you)
  • I don’t want to bring it to work – “IT WAS YOU!”
  • AND I’m a doctor – walk the walk – I’m a believer

If you have influenza – stay home, rest, take fluids, medications like ibuprofen to feel better (don’t give aspirin to kids or adolescents).  If you worsen seek medical advice or help.   Don’t return to work until your fever is gone for 24 hours – you’ll know, the relief is remarkable.

Vaccine, cover, wash, recognize, stay home.

And Now for Something Completely Different

By Jeff Ribordy M.D., Regional Medical Director

As medical directors at Partnership HealthPlan of California, we are honored to review an array of medical records, treatment authorization requests and sundry other medical documentation on a daily basis. Every so often we encounter documentation that makes us scratch our heads and entices a chuckle. Here are some of the best-

Before the current “Golden Age” where everyone has an EHR and now loves charting endlessly (sarcasm intended) there were these things called “medical errors”. I know it’s hard to fathom, doctors making mistakes, but it’s not just fake news. Most of the “errors” were typically related to undecipherable hieroglyphics known as “doctors’ handwriting” leading to medication mistakes or other orders either being ignored or completed incorrectly.

While typed or dictated notes now allow legibility, comprehension can still be a struggle. Whether from stream of consciousness HPIs, dictation errors or excessive reliance on standard templates without reviewing, errors still are found. In our review of submitted medical records we have found a few mistakes that make us chuckle or even laugh out loud. I’m going to share some of these here – not to point fingers but with the understanding we all have made similar mistakes.

Sometimes we have to take a patient’s history with a grain of salt…

Fig 1

From the category of “How Do You Find The Time To Do Anything Else”:

Fig 2

 From the Physical Exam:

Fig 3

Family history can be…very revealing:

fig 4

And from the Catch-All category of “Huh?”:

fig 5

And good advice for everyone:

fig 6

When to Consider Palliative Care/Hospice for Patients with Advanced Dementia

Written by: Scott Endsley, MD, MSc., Associate Medical Director for Quality

Dementia is a terminal illness, like cancer or advanced heart disease. Dementia is rapidly increasing in the U.S. and worldwide. In 2012, there were over 5.2 million Americans with Alzheimer’s Disease (AD). By 2025, the number is expected to grow by almost 30% to 6.7 million.[1] Along with the prevalence expanding at epidemic proportions, mortality also continues to increase. It is the 5th leading cause of death in the U.S.[2]

Dementia is a progressive disease with seven stages (figure 1). Alzheimer’s Disease may last for decades, though the mean in eight years. The Global Deterioration Scale[3] is a validated instrument that is helpful in staging the patient along the progression timeline. Memory and function loss proceeds inexorably across the stages until Stage 7 in which the patient has very limited words, incontinence, severe function loss requiring assistance for ADLs, and total disorientation. Median survival in Stage 7 is 1.3 years. Over 80% of patients in this stage have significant eating problems, often requiring assistance. Resultant weight loss is common. Infections, primarily pneumonia and urinary tract infections, are common and carry a high risk of mortality (40% or greater in the CASCADE study[4])

Palliative care is appropriate at any point after diagnosis and may be provided along with symptom management as early as Stage 2. Caregivers and providers are often confronted with the agonizing decision of anticipating death and entering the patient into hospice. Prognostication in advanced dementia is a problematic endeavor. The ADEPT tool has been developed to assist in predicting survival based upon eleven variables in demographics, cognitive status, functional status, active diagnoses. Risk scores greater than 16 (scale 1-32) suggests a six month probability of dying of > 50%. The Medicare Hospice guidelines requires the patient to have significant functional limitation (Stage 7 or beyond of Functional Assessment Staging (FAST) scale) AND at least one of six medical complications in the preceding year including aspiration pneumonia, pyelonephritis, septicemia, multiple decubitus ulcer, recurrent fevers after antibiotics, or inadequate hydration and caloric intake with 10% body weight during previous 6 months (or serum albumin less than 2.5 g/dl). When compared to the ADEPT prognostic tool, the Medicare Hospice guidelines perform less reliability in predicting 6 month mortality.

seven stages of dementia

Recommendations. As your patients with dementia of any type (Alzheimer, vascular, Lewy body) progress through the seven stages, consider the following:

  • Educate caregivers on the nature of dementia as a progressive and ultimately fatal disease
  • Initiate advance care planning conversations early (stage 1 or 2)
  • Ensure that a surrogate has been identified to medical decision making
  • Start palliative care in addition to other medical care early or at least by Stage 5 or 6.
  • Manage symptoms (neuropsychiatric, incontinence, insomnia) appropriately
  • Recommend caregiver assistance early to avoid burn-out and depression
  • Consider hospice evaluation at Stage 7

 

Resources. Many dementia management resources are available. Consult these as needed.

Alzheimer Association: www.alz.org

National Institute for Aging: www.nia.nih.gov/health/alzheimers-dementia-resources-for-professionals

National Hospice and Palliative Care Organization:  www.nhpco.org/resources-access-outreach/dementia-resources

[1] Alzheimer’s Association. 2012 Alzheimer’s disease facts and figures, accessed at: www.alz.org/downloads/facts_figures_20122.pdf

[2] Tejada-Vera B. “Mortality from Alzheimer’s disease in the United States. NCHS Data Brief. National Center for Health Statistics, Hyattsville, MD 2013

[3] Reisberg B, Ferris SH, de Leon JJ, Crook T. “The Global Deterioration Scale for assessment of primary degenerative dementia”. Am  J. Psychiatry (1982), 139: 1136

[4] Mitchell SL, Teno JM, Kiely DK et al. “The Clinical Course of Advanced Dementia”, NEJM, (2009), 361:1529

What to Know but Not Forget About Dementia

CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.

Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:

  • Memory loss that affects daily living or work
  • Difficulty performing familiar tasks
  • Problems with language
  • Disorientation in time and space
  • Poor or decreased judgement
  • Problems with abstract thinking
  • Misplacing things
  • Changes in mood or behavior
  • Changes in personality
  • Loss of initiative

Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment.  This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.

Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.

If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:

  • Behavioral modifications (scheduled toileting)
  • Music especially during meals and bathing
  • Walking or light exercise
  • Pet therapy (yes with animals, not electrons)
  • Cognitive exercise

Costs of Drugs for Treatment of Type 2 Diabetes Mellitus

The PHC Blog article on February 6, 2017 gave a very nice overview of the American College of Physicians (ACP) newly released guideline on treatment of Type 2 Diabetes (DM2).  I will quickly summarize: start with metformin, then add another medication as needed based upon side effect profile and patient characteristics.

This guideline is very similar to the ADA guidelines.  I appreciate the ACP attempt to look at side effects of the different classes of DM2 medications and to avoid certain medications in patients with pre-existing medical conditions.  The guideline however doesn’t provide guidance on medication selection based upon cost..  Why does cost effective prescribing matter?  Because for every dollar PHC spends on medications, we have to spend less on other health care or enhanced benefits.  PHC is a non-profit organization with a 4% overhead.  There is not much room for un-necessary spending.

Let’s start first with a simple table of the various choices:

Class Example Action Cost per month
Biguanide Metformin Decrease hepatic glucose, increase insulin sensitivity < $5
Sulfonylurea Glipizide Increases pancreatic insulin secretion < $5
Meglitinide Repaglinide Increases pancreatic insulin secretion $60
Thiazolidinedione Pioglitazone Decrease hepatic glucose, increases insulin sensitivity $10
DPP-4 Alogliptin Increases pancreatic insulin secretion $430
GLP-1 RA Liraglutide Increases pancreatic insulin secretion $550+
SGLT-2 Canagliflozin  ncrease urinary glucose secretion $430

Metformin:

Metformin is the first choice in all guidelines.  Metformin decreases hepatic glucose and increases insulin sensitivity.  Start slow (500 mg with the evening meal) – Start slow with 500 mg once daily with the evening meal and, if tolerated, add a second 500 mg dose with breakfast. The dose can be increased slowly (one tablet every one to two weeks) as necessary (per UTD)..  The longer acting ER formulation has fewer GI side effects and is on the PHC formulary. Metformin is contraindicated for patients with a GFR < 30.  Consider dual therapy at the outset for patients with an A1c > 9% at diagnosis.

Next Steps:

If not at target at 3 months with metformin, diet and exercise, add a sulfonylurea (SU) or basal insulin.  Repaglinide is an option for patient who don’t reach goal with metformin and cannot take a sulfonylurea and who wish to avoid insulin.  It is short acting and may be better for people who skip meals.  Pioglitazone is another choice after metformin and a SU, but it should be avoided in patients with a history of heart failure.  Generally, a third oral agent will not get a patient to goal however if the A1c is over 8% on metformin and a second oral agent.

DPP-4 Inhibitors:

Dipeptidyl-peptidase-4 inhibitor drugs, such as alogliptin, work to increase pancreatic insulin secretion and suppress hepatic glucose production.  They may decrease an A1c by 0.5 to 1%.  A DPP-4 drug may be considered when your patient is close to target, but not yet controlled on metformin and insulin. Alogliptin is a step agent for PHC and is covered if the Rx claims history shows fills for metformin and a second agent (oral or basal insulin).

GLP-1 Receptor Agonists:

Liraglutide is the preferred glucagon-like peptide-1 receptor agonist for PHC. GLP-1 agents increase insulin secretion, suppress hepatic glucose production and slow gastric emptying and thereby increase satiety.  They can decrease an A1c by 1 to 1.5%.  They may be appropriate agents for patients with a BMI > 30 for patients on metformin and a second oral agent or basal insulin.

SGLT-2 Inhibitors:

Canagliflozin and other sodium-glucose cotransporter 2 inhibitors work by lowering the renal threshold for glucose and increase urinary glucose excretion.  The dose has to be adjusted for renal insufficiency. Side effects include UTIs, yeast infections and weight loss.  They may also increase LDL cholesterol.

Ultimately, your patient needs what he or she needs after treatment with diet and exercise.  The medications will cost what they cost, but it is possible to make cost effective choices that get our patients to goal if we choose with care.

James Cotter, MD MPH; Linette Rey, PharmD