Something Easy

One of the least expensive medications is one of the most important in preventing heart attacks. Daily low dose aspirin (81 mg) will help prevent blockage of a coronary artery, reducing the risk of myocardial infarction. It’s hard for me to believe, but many patients will stop taking a daily aspirin even if they have already had a heart attack. An article in the British Medical Journal found that one-half of patients prescribed a low-dose aspirin regimen become non-compliant after a few years. People with heart disease who quit their low-dose aspirin regimens are at increased risk of non-fatal myocardial infarction compared with those who remain compliant. For every 1,000 patients, there were about four more cases of non-fatal myocardial infarction per year among patients who'd recently stopped taking low-dose aspirin.

Not every patient should take a daily aspirin, since there are some risks associated with it. A physician will help decide if the benefits outweigh the risks. There are few medications that are as inexpensive or effective. (Here’s a clinical pearl: don’t buy the warehouse size bottles of aspirin. If you buy a bottle of 500 pills, 400 will probably need to be discarded. If you smell vinegar, the pills are starting to break down – throw them out.)

BMJ 2011; 343:d4094

Mammograms?

Cancer experts agree that mammograms save lives. It is not clear how to balance the benefits of early detection against the risks of screening. False positive mammograms may lead to invasive diagnostic procedures that are expensive, cause worry and may cause harm. The majority of the current recommendations about mammography timing are age based. Women are not all the same; a more nuanced set of recommendations is being developed. A group of researchers from the University of California and other institutions consider other factors that influence risk when making decisions about mammograms: family history of breast cancer, breast tissue density, history of previous breast biopsies as well as a woman’s own preferences.

A spokesperson for the American Cancer Society notes that public health campaigns work best when they are simple. If there are too many considerations, it is difficult to convey an understandable message to the public. It is clear that periodic screening for breast cancer is important – every woman should have a conversation with her physician about what is right for her.

Electronic Health Records

The electronic health record (EHR) will replace paper charts - a refrain that I have been hearing for at least ten years, but the volume of the clamor has been steadily increasing for the past five years. The noise is now nearly deafening, since the federal government is offering physicians financial incentives to adopt EHRs. The maximum reimbursement for expenses incurred to install an EHR (estimated to be up to $100,000 per physician) will be $44,000 paid over five years once some very stringent criteria are met.

The New York Times published an excellent analysis in Sunday Business this week: http://www.nytimes.com/2011/07/17/technology/assessing-the-effect-of-standards-in-digital-health-records-on-innovation.html?ref=business. “ …when well designed and wisely used, digital records can deliver the power of better information to medicine, improving care and curbing costs.” Unfortunately, EHRs as now designed are cumbersome, slow and not at all aligned with the ways physicians and patients interact. I take notes while my patient and I chat. Since patients don’t relate their histories in a linear way, my handwritten notes will jump around a bit as I organize the story. Sometimes, in the middle of talking about sinus congestion, the patient will make an off-hand comment that a parent has an unusual, inherited disease or ‘when I was 10 I stopped breathing after a penicillin shot.’ With the paper record, I can seamlessly add this vital information to the family history or list of allergies. This is not so easy in an EHR. I am very familiar with an EHR offered by a very large company. Adding information such as this means closing down the history of the present illness window, opening the allergies or family history window and finding the correct tabs (and codes!) for this information. A less than diligent physician might not go to the trouble.

Software engineers are not physicians nor do they think like physicians. When attempting to document a past medical history in an EHR, I was unable to find “varicella” as a key word. The person writing the program figured that regular people use the term “chicken pox,” so that was the only was to enter the illness. I have an app in my pocket with key diagnosis codes – but even that information didn’t allow me to work around this barrier.

I’ll be sticking with paper records for now, even as I have embraced electronic prescriptions. The prescription vendor that I use won’t allow me to make a careless error and has a drug interaction and drug allergy systems that reassures me that primum non nocere (first do no harm). Any EHR will need to do the same for me to purchase it.

Health Literacy

There is a growing comprehension gap that physicians need to bridge to ensure that their patients can manage their health. Doctors simply need to work harder so that patients can understand basic health information and make appropriate health care decisions.

Understanding medical treatment involves the comprehension of a new language, one with its own set of concepts, jargon and statistics. All patients can benefit from clearer communication but patients with chronic health conditions need to understand instructions in order to juggle medications, diet and treatment regimens. Patients with low health literacy face a higher risk of death. Level of education, life experiences and culture can shape how patients perceive and process vital health information.

Physicians cannot guess their patients’ health literacy. Studies have shown that patients are not insulted if information is “dumbed down;” patients welcome hearing a simple explanation and a clear plan. This is especially true in patients with limited English efficiency. The best way for physicians to improve communication with patients is to place close attention to the words they use, the points that they want to make and how the patient responds.

Increasing health literacy is a priority objection in Healthy People 2020, a federal plan for improving American health. Doctors need to communicate in ways that patients can understand and act on – and patients should hold doctors accountable to do so. 

Pat the Bunny - but be careful

It’s summertime, and many of us are looking for fun and interesting things to do. Contact with animals in public settings (e.g., fairs, educational farms, petting zoos, and schools) provides opportunities for entertainment and education. Although human-animal contact has many benefits, human health problems are associated with these settings, including infectious diseases, exposure to rabies, and injuries.

Injuries associated with animals in public settings include bites, kicks, falls, scratches, stings, crushing of the hands or feet, and being pinned between the animal and a fixed object. Infections from animal bites are common and frequently require extensive treatment or hospitalization.

Infections with enteric (intestinal) bacteria and parasites pose the highest risk for human disease from animals in public settings. Healthy animals can harbor human enteric pathogens, many of which have a low infectious dose (only a few bacteria are needed to make someone very sick). The prevalence of certain enteric pathogens is often higher in young animals, which are frequently used in petting zoos and educational programs for children.

Children aged less than 5 years are at particularly high risk for serious infection. Other groups at increased risk include persons with waning immunity (e.g., older adults) and persons who are mentally impaired, pregnant, or immunocompromised (e.g., persons with human immunodeficiency virus/acquired immunodeficiency syndrome, without a functioning spleen, or receiving immunosuppressive therapy). Persons at high risk for infection should take heightened precautions at animal exhibits. In addition to thorough and frequent hand washing, heightened precautions could include avoiding contact with animals and their environment (e.g., pens, bedding, and manure). Animals of particular concern for transmitting enteric diseases include young cattle, live poultry, reptiles, amphibians, and ill animals.

Education of visitors to public animal contact venues about the risk for transmission of diseases from animals to humans is a critical disease-prevention measure. Contact with animals should occur in settings where measures are in place to reduce the potential for injuries or disease transmission.

MMWR/ May 6, 2011 /Vol. 60/ No. 4