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HospitalistWeekly 10-29-08

Highlights

• Uninsured wrongly blamed for ER overcrowding
• Americans cut back on doctor appointments, pills to save money

Cardiology

• Sudden cardiac death is No. 1 mortality risk for dialysis patients
• Heart failure patients have higher fracture risk

From ACP Hospitalist

• Take our pre-election poll

From ACP Internist

• On the blog: highlights from Chest 2008

Cartoon caption contest

• October's winning entry

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Highlights

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Uninsured wrongly blamed for ER over-crowding

The widely held belief that uninsured patients are responsible for U.S. hospital emergency room overcrowding is a fallacy based on mostly unsupported assumptions, according to a study in the Journal of the American Medical Association.

While just 17% of the approximately 115 million annual ER visits are made by patients without insurance, growing demand for emergency services is often blamed on uninsured patients. They are actually less likely than insured patients to visit the ER for non-urgent problems, and a higher proportion of Medicaid and Medicare patients use emergency departments than the uninsured.

Researchers performed a literature review of clinical topics concerning uninsured patients and ER care and found that out of 127 articles, 53 had at least one assumption about uninsured ER patients, with a mean of three assumptions per article. The six most frequent assumptions found were that uninsured patients present with non-urgent problems, lack primary care, are increasingly presenting to ERs, cause crowding, present more often than insured patients, and are more expensive to treat in the ER. Of theses six assumptions, three were not clearly supported by current data and three were true for both insured and uninsured patients.

The authors point out that if potential solutions to ER overcrowding are based on inaccurate information, problems will remain.

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Americans cut back on doctor appointments, pills to save money

Nearly half of Americans say they or a family member have skipped pills, and/or postponed or cut back on health care appointments and screenings in the past year to save money, a Kaiser Family Foundation poll said last week.

Thirty-six percent of interviewees said they or a family member didn't pursue medical care they needed, and 31% skipped a recommended test or treatment as of early October, the report said. That compares to 29% and 24%, respectively, in April 2008. About 20% of those who reported skipping care in October said their conditions got worse as a result.

In addition, 27% said they or a family member didn't fill a prescription, and 22% said they cut pills or skipped doses compared to 23% and 19% in April, the poll said. Twelve percent had problems getting mental health care, up 4% from April.

About one in three reported their family has had problems paying medical bills in the past year, up from about 25% two years ago. Of those who make less than $30,000 per year, 46% reported problems paying medical bills, according to the October Kaiser Health Tracking Poll: Election 2008. Those who reported problems said the bills were in the thousands of dollars, not the hundreds. Lower-income families were more likely to skip or postpone appointments.

U.S. hospitals are also reporting an increase in emergency room patients recently, including more uninsured patients, and elective surgeries and diagnostic tests at hospitals have fallen 1-2% in recent months, compared to a usual increase of 2-4% per year, the Oct. 22 Washington Post reported.

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Cardiology

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Sudden cardiac death is No. 1 mortality risk for dialysis patients

Sudden cardiac death (SCD) emerged as the No. 1 cause of death for dialysis patients on dialysis, according to a Johns Hopkins study soon to be published in Kidney International.

The study identifies systemic inflammatory response and malnutrition, both common among end-stage renal disease (ESRD) patients, as key risk factors for the fatal heart attacks. The stress of kidney failure, loss of appetite and a highly restricted diet are responsible for the prevalence of malnutrition in this population.

A 10-year retrospective analysis of more than 1,000 ESRD patients showed that out of 658 patient deaths, 146 were the result of SCD. Blood test results revealed that patients with high levels of either hsCRP or IL-6 were twice as likely to die from SCD as those with low levels of these proteins. Low albumin levels were associated with a 1.35 times greater risk of dying of SCD than high levels, and those with low levels of albumin and high levels of hsCRP were four times more likely to die of SCD than those with high levels of albumin and low levels of hsCRP. Results indicate that ESRD patients with low albumin and/or high IL-6 and hsCRP are at a significantly higher risk of SCD.

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Heart failure patients have higher fracture risk

Patients with heart failure may have an increased risk of hip and other orthopedic fractures, suggesting that they should be screened and treated for osteoporosis, a recent study found.

Using a population-based cohort of patients age 65 or older who presented at emergency rooms for cardiovascular disease over a three-year period, researchers compared 2,041 patients with a new diagnosis of heart failure (HF) with a control group of 14,253 patients with non-HF cardiovascular diagnoses. In the year following the ER visit, 4.6% of the HF patients sustained an orthopedic fracture (1.3% sustained hip fractures), compared with 1% of the control group (0.1% hip fractures). The study was published online Oct. 20 by the American Heart Association journal Circulation.

The mechanism linking heart failure and fractures is unclear, said the authors in an AHA news release. They speculated that possible reasons for the association might be elevation of the parathyroid hormone as heart failure worsens; poor adherence to strict diets prescribed for heart failure patients (such as insufficient vitamin D); and lack of exercise. The findings highlight that many older adults are not getting adequate screening and/or treatment for osteoporosis, they added.

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From ACP Hospitalist

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Take our pre-election poll

With Election Day approaching and so many casting early ballots, ACP Internist and ACP Hospitalist are asking readers which candidate's health care plan they favor, Sen. John McCain or Sen. Barack Obama, and whether their proposed health care reforms will influence your vote.

Need help deciding? ACP has a toolkit that analyzes the candidate's plans, then vote. Cast your ballot by Nov. 5; results will appear in an upcoming issue of ACP InternistWeekly. (This poll is not considered scientific and does not constitute an endorsement by the American College of Physicians.)

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From ACP Internist

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On the blog: highlights from Chest 2008

ACP Internist highlights the best of Chest 2008, as well as Medical News of the Obvious, new every Monday.

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Cartoon caption contest

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October's winning entry

ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Matt Thorpe, ACP Student Member, a first-year student in the MD/PhD program at the University of Illinois at Urbana Champaign. He will receive a $50 gift certificate good for any ACP product, program or service. Readers cast 260 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

"Actually I was an ass before I went to medical school."

The winning caption received 45.4% of the votes cast. The runners-up were:

"I know it's shocking, but that's the standard of care for a broken leg." (37.7%)
"Once I figured out how to talk, I decided medical school couldn't be that hard." (16.9%)

The cartoon contest continues in the Nov. 5 issue of ACP HospitalistWeekly.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated