Primary Care Survey: The Mystery Doctor Shopper

Here is an interesting article recently published in the New York Times. Alarmed by a shortage of primary care doctors, The Department of Health and Human Services is recruiting a team of “mystery shoppers” to pose as patients, call doctors’ offices and request appointments to see how difficult it is for people to get care when they need it. The survey is expected to begin soon and is expected to provide empiric data of primary care access limitations to insured people.

Although the data is meant to be summarized in aggregate, and not meant to identify individual practices or practice, the response from some physicians has been less than enthusiastic. Quoted in the article are colleagues likening the practice to 'Big Brother' and 'government snooping.' Predictable.

As an epidemiologist working in hospital infection prevention, we are frequently faced with policy decisions. We find that collecting, analyzing and summarizing data leads to more evidence based, emotion-free decision making. Hence, a survey such as this may prove useful.

For those that disagree, if one were to attempt a voluntary, anonymous self administered (by physicians) questionnaire of primary care access, the response rate would be exceedingly low (due to busy schedules), would not be representative, and would likely be very biased. 

Bad science.

The Hospital Environment is Teaming with Bacteria: Implications for Infection Prevention

It likely comes as no surprise that the hospital environment (inanimate objects, including stethoscopes), harbor pathogens of importance. Here is a state of the art review article on the role played by contaminated surfaces on the transmission of hospital acquire infections.


Contaminated surfaces contribute causally to infections with Clostridium difficile, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, and norovirus. 


The challenges are multiple. Hospital pathogens can survive on surfaces for long periods. There are limitations to cleaning and disinfection such that environmental surfaces cannot be completely sterilized. Hospital pathogens can be transferred from contaminated surfaces to the hands of the healthcare workers, then to patients. Last, better studies to determine the relative effectiveness of various infection prevention interventions are needed.


The importance of hand hygiene by healthcare workers cannot be overlooked.  Hands are continuously contaminated during the course of hospital activity and must be meticulously washed immediately before and after all patient care.


There are no short cuts.

TB in the USA- Recent Epidemiology

I work in a large university hospital that provides care to the urban poor. Tuberculosis is frequently on the differential diagnosis and we commonly treat active tuberculosis every year.  This recent review on the epidemiology of Tuberculosis in the USA, published in the American Journal of Public Health, is eye opening.

Several points are noteworthy. The authors found  42,448 patients with TB in 48 cities accounted for 36% of all US patients with TB. These cities comprised 15% of the US population. In these cities, the TB incidence rate in (12.1 per 100,000) was higher than that in the US excluding the cities (3.8 per 100,000). Nineteen cities had decreasing rates; 29 cities had nondecreasing rates. There were no consistent patient variables to predict cities with decreasing or nondecreasing TB rates.  

A significant TB burden still occurs in large US cities and more than half (60%) of the cities studied did not show decreasing TB incidence rates. 

It seems like we have much to learn about factors impacting TB control in US cities, including city-level variations in migration, socioeconomic status, and resource allocation.

Cocaine and Antihelminthics Don't Mix Well

Purpura on the ear
Source ABC News

This one is bizarre.


Reported here, in the Journal of the American Academy of Dermatology, and also here on ABC news; cocaine laced with levamisole (a veterinary drug for de-worming [antihelminthic]) is associated with purpura and vascultis, resulting in a 'flesh eating' reaction of sorts.


The authors reported 6 remarkably similar patients seen over a few months with purpura on the body and tender purpuric eruptions, necrosis, and eschars of the ears after cocaine use in New York and California.  These patients had positive perinuclear antineutrophil cytoplasmic antibody (P-ANCA)  values and half had neutropenia. The findings suggested an immune complex-mediated vasculitis.


Cocaine and antihelminthics mix poorly and result in a drug that stimulates even the immune system. 


No bueno.

Infection Control of Multidrug Resistant Organisms: What Works Best is Still Not Fully Defined

I quickly perused this paper with my morning coffee.

Bundled infection prevention practices, particularly for the control of multidrug resistant organisms (MDROs), remain common interventions. The authors performed a scholarly and comprehensive review of the literature.

The conclusion: The review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO infections is weak. There are significant methodologic weaknesses in the MDRO control literature. It is unclear which bundles of interventions are effective. The review suggests, however, that multiple, simultaneous interventions can be effective in reducing MDRO infections.

Here is my take on things: Although we have made much progress in infection prevention, the current state of science and practice is still not sophisticated enough to avert all hospital acquired infections.

Have a fine weekend.

A Pictorial Guide: Smoking is Hazardous to Your Health

Permit me to stray from my area of expertise, infectious diseases, and move on to smoking cessation.

The US Government has released new images that will cover the upper half of the front and back of cigarette packages produced after September 2012, as well as 20 percent of the space in cigarette advertisements.

The images are graphic and to the point. There is an informative article here.

Tobacco manufacturers, predictably, are not pleased. When you produce and sell a product that remains the leading cause of preventable death, killing 443,000 Americans a year according to the Centers for Disease Control and Prevention, you should not expect much sympathy.

Quinolone Use and Influenza Activity

Not sure why I am on an antibiotic kick at the moment. Perhaps it is because I am again staffing the Infectious Diseases consult service this week and seeing a lot of unnecessary antibiotic use.


Hot of the press: using a time series model, researchers from the University of Iowa report that respiratory fluoroquinolone use is highly seasonal and that fluoroquinolone use is strongly associated with influenza.


The use of respiratory quinolones during influenza season may reflect the clinical challenge of differentiating, at least on initial presentation, between viral and atypical bacterial pneumonias.  Quinolones may also be correctly prescribed for secondary bacterial infections following influenza. 


Perhaps, more cynically, they are used for their 'anti-viral' effect.

Physicians' Perceptions about Antimicrobial Use and Resistance

All hospitals are now required to have some sort of an an antibiotic management (stewarship) program. The goal of these programs is to avoid antibiotic overuse, minimize antimicrobial resistance, reduce adverse events and limit expense.

Investigators from the University of Miami School of Medicine surveyed faculty and resident physicians to learn of attitudes, perceptions and knowledge about the antimicrobial resistance and their stewardship programs. The results appear encouraging, as most respondents were concerned about resistance when prescribing antibiotics, agreed that antibiotics are overused, felt inappropriate use is professionally unethical, and that others, but not themselves, overprescribe antibiotics.

The last point is both enlightening and reminiscent. This is much like hand hygiene. Everyone agrees that hand hygiene is important and everyone overestimates their degree of (stellar) adherence with washing their hands.

Reconciling physician practice with self reported adherence, either with hand hygiene or antibiotic prescribing, will continue to be a challenge.

HIV Infection and Persons with Disabilities- Not Mutually Exclusive

As an infectious diseases and HIV specialist, the title of this Sunday's New York Times opinion article caught my eye.

I too am guilty of not giving the topic much thought and in assuming that all disabilities — of hands, feet, hearing, sight — somehow also affect the ability and desire to have sex . It is tragic that people with disabilities are rarely exposed to sex education and are almost never considered in need of information about H.I.V. and treatment for it. 

Although people with disabilities are as likely as anyone to have sex, their rates of HIV infection are reportedly 3 times higher.  Alarming and worthy of special focus for prevention efforts.

HIV epidemiology is more diverse than you think.

Needless Double CT Scans

Here is an enlightening article, published today, in the New York Times. It deals with unnecessary CT scanning of patients, the potential dangers and the additional costs.

Double CT scans (scanning patients twice in one day) expose patients to extra radiation while heaping millions of dollars in extra costs on an already overburdened Medicare program. There is widespread variation within the country on the practice of double scanning. Double scanning is more likely to occur at smaller, community hospitals.

 

Some physcians feel that double scanning will lead to additional clinical information, but there appears to be little data to support this notion.

The principal challenge is getting physicians to change practice.  

Convenience Stores May be Bad for Your Health

A recent study in the American Journal of Preventive Medicine examined the relationship between the presence of neighborhood food stores within a girl's neighborhood and 3-year risk of overweight/obesity and change in BMI.

The results are interesting. Availability of convenience stores within a 0.25-mile network buffer of a girl's home was associated with greater risk of overweight/obesity (OR=3.38, 95% CI=1.07, 10.68) and an increase in BMI z-score (β=0.13, 95% CI=0.00, 0.25).  However, the availability of produce  markets within a 1.0-mile network buffer of a girl's residence was inversely associated with overweight/obesity (OR=0.22, 95% CI=0.05, 1.06).

The study neither assessed the food items in the stores nor individual food product consumption by study participants, as such, direct causality cannot be established. 

The suggestion, however is clear.The empty calorie slurpee is right around the corner.

No Free Lunch! Medical Students and Pharmaceutical Companies

This is an interesting title that caught my eye.

The study explores medical student exposure and attitudes about pharmaceutical companies. What I found disturbing was that the clinical year students found promotional materials helpful for their education, particularly on drug prescribing.

This is simply another ploy to influence practice by industry.  With every pharmaceutical industry encounter, there is an underlying quid pro quo.

Never learn your medicine from a pharmaceutical representative. 

There is No Free Lunch.

 

Mobile Phones and Drug Resistant Bacteria: Mobile Pathogens?

Technological Terror: Mobile Phones Carrying Resistant Bacteria?

Mobile phones are pervasive.

A recent study published in AJIC assessed bacterial colonization on the mobile phones used by patients, patients' companions, visitors, and health care worker.  Significantly higher rates of pathogens (39.6% vs 20.6%, respectively; P = .02) were found on the mobile phones of patients' (n = 48) versus the HCWs' (n = 12). There were also more multidrug pathogens in the patents' mobile phones. These includied methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Escherichia coli, and Klebsiella spp, high-level aminoglycoside-resistant Enterococcus spp, and carabepenem-resistant Acinetobacter baumanii. The authors suggest that mobile phones of patients, patients' companions, and visitors represent higher risk for nosocomial pathogen colonization than those of HCWs.

The inanimate environment is teeming with pathogens so this finding is not so surprising. Unless the colonized phone of a patient or visitor travels from room to room and comes into contact with other patients or HCWs, then the risk of cross transmission is small.

Short of banning phones or insisting that they be wiped down with chlorhexidine upon entry and exit of a patient room, what else can be done?  Should the phone don gloves too by inserting it into an examination glove?

White Lies from the White Coats

Well, the first day back was busy indeed, with a daunting, unsolicited, bureaucratic, mountainous paper heap to get through. I survived unscathed.


A colleague sent me an interesting article on white lies by the medical profession, all in the name of patient care. Physicians tell lies to circumvent perceived hurdles in patient care such as admission diagnoses, diagnostic tests, and restricted antibiotics.


What about lying to patients and withholding information? The literature is sparse on the exploration of this theme. One author suggests that, in some circumstances, withholding the truth to protect hope can be considered a morally acceptable option when truth-telling has the potential to destroy hope's therapeutic effects. Another author concludes that there can be no moral justification for lying to patients.

I will leave the final moral decision on truth telling to you.

Contact Precautions and Depression

Well I am back in the USA as some of you blog followers may already know. Admittedly, it is a bit difficult to re-adjust to the practice of medicine in the USA. Strangely, I miss the chaos and grime of Central America. Changing the focus of my blog to '1st world' medical issues is challenging too, but here goes.

There is ongoing debate about the adverse, unintended consequences of contact  precautions. The literature suggests that patients in contact precautions suffer greater feeling of isolation, depression, fewer provider visits and greater adverse events.

A large, retrospective analysis published in Journal of Hospital Infection  assessed the relationship between contact precautions and depression or anxiety. During the two-year period, there were 70, 275 admissions. After adjusting for confounders, contact precautions were associated with depression [odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2–1.5] but not with anxiety (OR 0.8, 95% CI 0.7–1.1). Depression was highly prevalent among patient on contact precautions.

Widespread implementation of active detection and isolation for MRSA, VRE colonized patients is bound to have adverse consequences. Perhaps the focus should be on a least restrictive alternative, such as meticulous and relentless pursuit of hand hygiene compliance.

Back to the daily grind.

Honduras- Homeward Bound, Day 11

We have come full circle.

The VCU Internal Medicine Team is back in San Pedro Sula Airport, en route to the glamorous USA.

Best medical relief trip to date.

Back to the hospital on Monday.

GB

Honduras- Pictures Continued

Her are a few choice pics that were omitted earlier.

GB

Honduras Photos From Last 2 Days

Here are a few snaps from the last few dates including patients in waiting, VCU Medical Students, colleagues and my typical Honduran meal.

More to come, soon.

GB

Honduras Days 9-10

About 1000 patients seen in 8 days.

The clinic was exceedingly busy on the last day.

Our medical students were uniformly superb, as were our residents, nurses and pharmacists.

At the end of the day, Dr. Stevens and I posed with legendary medical relief nurse, Annie Kautza.

Now in San Pedro Sula at a rather ritzy Hilton hotel. The lavishness is incongruent with the last 9 days in the poor countryside.

Back to the USA tomorrow. Will post more photos soon. The mobile blogger function on my smartphone is not functioning properly.

-GB

Honduras Day 8

Today proved busier than ever. It was pathology day, with some complicated diagnoses and vexing management issues, mostly due to a lack of access to consistent healthcare.

In the 3rd world, one has to be creative in search of a x-ray view book.

Our dentist was super busy extracting countless teeth.

At day's end, we wandered around the dusty and sun-bleached Olanchito city center. The people watching was superb, and, most likely, we were being watched too.

GB

Honduras Day 7

Another busy clinic day under rather uncomfortable heat and humidity.

No super unusual cases except for maybe larvae in an ear. This is not about exotica, after all, just basic medicine and public health.

At the end of the day we toured the local public hospital, which was both resource and personnel poor. The hospital morgue had a non-functioning chiller. Undesireable.

Our 2 IRB approved questionnaire studies are progressing nicely. Our dedicated student researcher, Kate Pearson, tirelessly inputs data at the end of the day.

Back to the grind tomorrow.

Ciao-

GB

Honduras Day 6

Yesterday was a free day. I walked around the 16th century Spanish fort in Trujillo and managed to snap a few shots.

Today I did a radio interview for local radio. Not sure that anyone was listening.

We are now in the small town of Coyoles, near the Dole banana plantation. Clinic was in full effect.

Not too many unusual cases today, but plenty to keep me interested.

Will keep you posted. Check back tomorrow.

GB

Honduras Day 2-5

Well, the last several days have been exceedingly busy.

We were in rural, mountainous Honduras. We have managed to see hundreds of patients. We have distributed water filters to the extremely poor so that the water quality prevent diarrheal illnesses. We have proceeded with mass deworming of children and adults.

The resident doctors, medical students and nurses have been uniformly superb.

The mobile blogging upload has been a bit problematic, so please be patient. I will post photos soon.

All in all, the trip is proceeding in fine fashion.

Ciao-

GB

Honduras Day 2- again

Drs. Sealand, Sharma and Jean Rabb, RN.

We are headed up the mountain and will be knee deep in medical work, water filtration project and patient care.

We will be incommunicado for 3 days. Many photos and updates upon our return.

Stay tuned.

Honduras Day

Early morning with Dr. Michael Stevens. Will be off to the mountains, later.

More to come.

Back in Honduras- Day 1

At the airport, in San Pedro Sula, with VCU Internal Medicine Nurses Iza Dragos, Jeann Rabb, and Hannah Farfour.

Tomorrow is bound to be a big day, as we are heading to the mountains, to see patients and install water filters.

Stay tuned.