Popular Hospitals May Not Be the Best Place to Have Surgery

In the era of Facebook "Likes," Yelp, and quick online surveys on every topic imaginable, it makes sense that we'd turn to patient satisfaction scores to help us decide at what hospital we -- or a family member -- will have surgery. After all, who better to tell us about the patient experience than other people?

Unfortunately, a new study by Johns Hopkins University School of Medicine researchers found that there was a big disconnect between the quality of what happens in surgery and the perception of patients about a hospital. The study was published recently in JAMA Surgery.

Surgical patients who reported they had a positive experience in the hospital did not necessarily get high-quality surgical care, according to the research. 

In other words, don't let a happy Facebook page or even a hospital's reports about patient satisfaction serve as a key factor in deciding where to go for surgery. The researchers found little evidence there was any correlation between patient satisfaction and quality.

There are certain factors -- typically not seen by a patient -- that contribute to high quality care.They don't sound very exciting, but research has shown that having certain routine procedures and safety factors in place make a big difference in how healthy you'll be after the surgery. Those factors include, for example, how well the hospital prevents potential complications like infections and blood clots, and how extensively staff are committed to and educated about  providing safe, error-free care. 

The researchers looked at quality measures and patient satisfaction data at 31 urban hospitals in 10 states. Medicare patient experience surveys were reviewed to identify the level of patient satisfaction. Quality was determined by how closely physicians and staff followed recommended standards of care.
 
Martin Markey, M.D., the lead author of the study, said satisfaction scores will mislead patients since they're going to feel that the "hospital with the best lobby and the best parking and customer service is going to have the best heart surgery."  

The researchers looked at quality factors that have been shown to improve surgical outcomes, such as the use of antibiotics to prevent infections; prevention of deep vein thrombosis (such as blood clots in the legs); prompt removal of bladder catheters; and the hospital's commitment to safety. 

They said  that while patient assessments may tell you something about the overall patient experience at a hospital, don't count on them to give you guidance about the quality of care related to surgery. 

And don't look to the Affordable Care Act to improve this problem. Patient assessments of quality account for 30% of the score that determines whether hospitals will get bonuses or penalties under the law's "value-based purchasing program."



What does this mean for you? 

• When your surgeon tells you what hospital you will be going to for surgery, ask whether you have a choice. You may not. Some surgeons only do surgery at one facility. If you do have another option, ask about the pros and cons of each facility, especially in terms of surgical outcome. 

• If you don't like the surgeon's answers or if you have concerns about the recommended hospital, consider getting a second opinion from another surgeon. 

• Don't be impressed with frills like valet parking or free Wi-Fi. Understand that quality surgery care is a little like air travel: no matter how good  (or bad) the in-flight entertainment or the mileage bonuses may be, your ultimate goal is to get where you want to go safely and with a minimum of drama.

• Be wary of hospitals advertisements and reports about patient satisfaction. Ask for hard data about key safety factors, including not just the ones the researchers used in this study (as noted above), but readmission rates, infection rates, adverse events, and average length of hospital stay for the surgery you're getting  (longer stays are often correlated with complications). 

The bottom line: Understand that when you're having surgery, you're not just choosing the surgeon. Other very important factors related to how you will ultimately fare include the quality of the hospital staff,  the hospital's routine policies and procedures, the level of nursing care, and the organization's commitment to patient safety. And while some of those factors may be difficult to know for sure, asking some questions beforehand may make a big difference for you and the people you love.



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Do Cough Medicines Really Work?

As a cold or the flu starts to get better, many people are hit with an annoying last phase: an irritating cough.

Long after a sore throat and nasal congestion goes away, a cough can persist for days and even weeks. Sometimes it's caused by swollen and sensitive airways that haven't healed, even though the virus has been fought off effectively.

That's good to know, but it doesn't make dealing with the problem any easier. Not only does a cough make going back to school or work difficult, it can be impossible to get a good night's sleep when you're hacking away.

However, before you reach for cough medicine, it's important to be sure you know what's causing the problem:

• What's really driving your cough? If it has been more than a week or two since your cold or flu, you should be sure you know what is actually the cause of your problem. If you have an elevated temperature or continue to feel ill, be sure to see your physician to make sure a bacterial infection -- such as pneumonia or a sinus infection -- hasn't settled in. 

• Your cough may, in fact, be unrelated to the virus you've just beaten. A cough -- especially not long after a cold or flu --  can also be caused by a range of conditions, including acid reflux, allergies, dry air, dehydration, or overuse of decongestant sprays (which dry out and swell your mucous membranes). Increasing the humidity in your home,   especially in your bedroom, and increasing the intake of non-alcoholic fluids may help. If you suspect your problem could be acid reflux, you can try over-the-counter remedies first, while restricting the acid in your diet, and if that doesn't work, should see your doctor. If you're a smoker, quit if you can, and get help if you're struggling with the challenge.

It's also critical that you know what  drugs can and cannot do. Surprisingly, there is little solid evidence that cough medicines work.

•  Centrally-acting cough suppressants, such as dextromethorphan, are designed to reduce how your body perceives the need to cough. They affect signals in the brain that trigger the cough reflex.  But studies show no benefit to these drugs in children or adults. Examples include Robitussin, Vicks Formula 44 and St. Joesph Cough Suppressant. Before taking any of these drugs, check for warnings and potential drug interactions.

•  Locally-acting cough suppressants include benzonatate (a non-narcotic capsule that  numbs the respiratory passages) and expectorants such as guaifenesin (which thins mucous, making it easier to cough up). Case studies of people with cancer have shown that benzonatate is effective, but that may not be true for others. Guaifenesin, (such as Mucinex, Robitussin, Guiatuss, Q-Tussin, Liqufruta, QTussin, MucaPlex, and Bronchoril) has been shown to thin mucous and help relieve coughs. 

• Non-drug options, such as menthol losenges and honey are often helpful.  Randomized controlled trials have found that honey was significantly better than placebo at reducing cough symptoms. (But, according to the American Academy of Pediatrics, products containing honey should not be used in babies under 1 year of age due to the risk of botulism in infants).

Other Approaches?

Sleeping with your head on a few big pillows often helps. Keeping your bedroom humidified and drinking a lot of fluids to think your secretions can be useful. If you're not getting much rest at night, try to sneak a nap during the day, since fatigue may make your cough even worse.

Remember, coughs normally can take up to 2 weeks to go away. But see your physician  if you're coughing up thick yellow or green mucous, have a fever, night sweats, are coughing up blood, or have chronic heart or lung disease.It's also wise to talk with your pediatrician before treating a child's cough.
 
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Is Your Doctor Clean and Sober?

It was one of those 2 a.m. phone calls you really don't want to get. 

I was a nursing administrator, and one of the departments for which I was responsible was Labor and Delivery.

The nurse on the phone was upset. "We have a patient who is about to deliver, and Dr. S. is here, but he is drunk," she said. "What should we do?"

 I phoned the E.R. to see if a physician could run up to the unit and help deliver the baby, but no one was free. So, with the nurse's help -- and a limited amount of Dr. S's oversight -- the baby was born.

I reported the situation to the hospital medical staff committee responsible for dealing with such issues. Dr. S. had his hand gently slapped -- and he continued to frequently show up in the middle of the night too inebriated to do his job.

It turns out this sort of thing isn't so rare. A commentary published online April 29 in The Journal of the American Medical Association argues that hospitals should be randomly testing physicians for drug and alcohol use, much as other organizations do.

Really? In hospitals? The authors of the commentary -- Dr. Julius Pham, Dr. Peter Pronovost and Dr. Gregory Skipper --  explain why there's such a difference between medicine and other high-risk industries that are also committed to keeping the public safe. In other words, how can this possibly happen?
  

• Medicine is under-regulated compared with other industries. the doctor-patient relationship is considered to be best governed by the profession, not other regulatory agencies.

• State and individual hospital system regulations tend to be weak.

• Self-monitoring is relied upon, and oversight is not good. For example, California has the largest number of U.S. physicians but its physician health program was recently discontinued.

• Frequently, a large number of cases have to occur before a hospital or state initiates an investigation.

The authors ask hospitals to take several important steps, including mandating physical exams, drug testing or both before a physician is added to the medical staff.  They also recommend random alcohol and drug testing for all physicians, and routine testing for any physician involved in a critical event leading to patient death. They say when a physician is found to be impaired, the hospital should suspend or revoke his or her privileges (the ability to see and treat patients at the hospital), and, in some cases, report the problem to the state licensing board. 

The authors point out that physicians are just as susceptible to alcohol and drug addiction as are the rest of us.

"Patients and their family members have a right to be protected from impaired physicians," write the authors. "In other high-risk industries, this right is supported by regulations and surveillance. Shouldn't medicine be the same?"

What can you do if you detect a drug or alcohol problem with your physician? It's a difficult situation because it is only natural to be concerned about impairing your relationship. But ask yourself: what would you do if you saw a drunk pilot walking into the cockpit?

• If you're in a hospital or clinic, report the situation immediately to a high-ranking staff member and tell him or her that you will follow-up in writing with your concern.
• Ask directly for another physician to oversee your care -- or the care of someone you love -- immediately. 
• If you have other physicians involved in your care -- perhaps specialists -- contact them and let them know you are concerned about the ability of the impaired doctor to look after your needs.

Everyone involved in health care is human. Physicians who struggle with drug or alcohol use need help, too.  Reporting a problem not only helps ensure that you and others will get needed care, you may be helping your doctor get the attention he or she needs, too.

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How to Find the Right Clinical Trial for You or Yours

For anyone facing a challenging disease or condition, participating in a clinical trial may offer hope for a new and better treatment. It can also provide the emotional reward of being an important part of expanding scientific and medical knowledge, thereby helping others.

But it can be tricky to know how to go about finding a trial that fits your situation, and to understand whether the possible benefits of the trial are worth the stated risks.

First, what's a clinical trial anyway? It's a rigorously controlled test of a new drug, invasive medical device, prevention strategy or other treatment on humans to evaluate whether the treatments will be made available for general clinical use. In the United States, trials studying new drugs and medical devices are under the direction of the Federal Drug Administration (FDA).  

Every year, there are about 144,000 clinical trials, according to the National Institutes of Health. Almost 40% of the studies are located in the U.S., and the others are in other countries.   

The number of clinical trials available is increasing every year, according to the National Institutes of Health

 About 80% of clinical trials are considered "interventional," which means they are testing either drugs or biologics, behavioral treatments, surgical procedures or devices. Almost 20% are observational studies (that means, for example, the participants are not separated in a group is that is getting the treatment and anothergroup  that is not getting the treatment, due to ethical or practical issues. ).

Some clinical trials are done by researchers, but most are performed by drug or device makers that are interested in bringing the discovery to market. 

If you're thinking about joining a clinical trial, there are lots of issues to consider and questions to ask. Once you identify a trial that is still recruiting participants, you have to be sure you "qualify" --  which mean that your health issue, gender, age and other factors meet the needs of the research that is going to be conducted. 

Be sure you understand the pros and the cons of participating, given your particular situation.You should discuss the trial opportunity with your physician, and also with the researcher, to learn what specifically would be required of you.

It's also important to consider the geographic location of the test, how often you would have to go to the facility for tests and evaluation, and whether that would work for you.  

You should know that most clinical trials -- but not all -- divide participants into two groups: those that get the treatment being evaluated and those that only get a placebo. Typically no one involved in the trial (neither the participants nor the staff) know whether you're getting the drug or something designed to look just like it. That allows the researchers to objectively evaluate whether the new treatment is truly effective.

Many people are frustrated to think they might go to all the trouble of participating in a clinical trial and only get a placebo. But sometimes the placebo patients are actually the lucky ones, as some drugs, devices or treatments cause problems or troubling side effects. In fact, sometimes people who on the placebo find themselves improving, perhaps because of the confidence they have in the trial or to other factors associated with the process.  

Clinical trials aren't for everybody. Some prefer to stay on their current course,(perhaps getting a treatment already approved by the FDA), rather than take the risk of receiving only a placebo. That is a choice every participant has to make.

Understand, too, that the only costs for which you would be responsible if you are accepted into a clinical trial are related to transportation, hotel and food (if you have to travel to the clinical trial site). 

How to find a clinical trial that would be appropriate for you? There are now a wide range of free websites, many of them quite new. Here are some examples:

• MyClinicalTrialLocator.com:  Just released in March, it is designed to help consumers more easily find clinical trials based on a wide range of factors. The site is updated 24 hours a day, uses information from academic medical centers and the U.S. government, and will notify users when a trial they are looking for becomes available.

• TrialReach: Based in London, this site's mission is to help those who may be interested in participating in trials, making them easier to find, understand and join. The site covers all conditions, worldwide.

• CenterWatch: Includes thousand of trials that are currently enrolling participants. Offers information on drugs and new medical therapies.  

• ClinicalTrials.gov: A U.S. government registry and results database of publicly- and privately-supported clinical studies of human participants conducted around the world. The site also offers information about clinical studies, history, policies and laws.

• ClinicalTrialsOn-Line: By the City of Hope, in Duarte, Calif. (a cancer hospital), the website allows visitors to search by type of cancer, phase of trial, and type (treatment, prevention, symptom management, quality of life, or others). 

• National Cancer Institute :  Part of the National Institutes of Health (NCI), the site allows you to search the NCI's more than 12,000 clinical trials that are now accepting participants. You can search by trial type, drug, or treatment intervention, and by trial identification number of sponsor. It also offers resources about clinical trials. 

•  FoxTrialFinder: For people with Parkinson's Disease, and for those without the disease who would like to volunteer to participate in a trial, the site provides an easy-to-search system. 

The bottom line: It's easier than ever to find clinical trials near and far that may offer you a chance at experiencing and testing a new treatment. They cover a wide, wide range of diseases and conditions. Even if you or those you love don't need or want a clinical trial now, it's smart to become acquainted with these sites and learn how they work. You also may be able to help a family member,

friend or colleague down the road.

Not Sure You Want a Second Opinion? It's Something Like Choosing Chocolates (Really!)

 Is deciding to get a second opinion something like looking at a box of chocolates?

It's really common to resist the idea of getting another point of view about whether you should have a serious test or procedure, surgery, or take a particular approach to treatment. Even though people know they may end up getting a better, more effective plan of care, they don't want the hassle, the potential extra cost, and the challenge of finding someone qualified to weigh in.

New consumer research suggests something else may be happening. Many people are eager to close a deal, or in the case of health care, to wrap things up. 

The study  I'm talking about comes from psychology, and it's called "Turning the Page: The Impact of Choice Closure on Satisfaction," published in the Journal of Consumer Research.

The research suggests that when people make a choice, they like closure. When someone limits your choices, your tendency to reconsider your options is reduced, and that makes you happier.  

In other words, once you're made a decision, seeing other options makes you frustrated or unhappy.

One of the experiments in the study involved asking people to pick just one from a variety of chocolates on a tray. After making their selection, some people were asked to cover the remaining delicacies with a lid.  Others could keep staring at the morsels they hadn't picked. 

Which group was happier with their choices? The ones who couldn't see the treats they had passed up. 

Another experiment involved having people select what they wanted to eat from a restaurant menu. 

Guess what? Those who closed their menus right after deciding were happier with their choice than were the others who could keep looking at a virtually endless list of options. 

Researchers say the study shows humans like closure. We tend to be happier with firm choices because we don't want to keep evaluating the pros and cons of an option. 

Think about your own personality. Does anxiety and indecision prompt you to rush toward a decision, even if you feel it might be a little under-researched or incomplete? 

If so, understand that that approach may be something you might need to overcome if you are ever faced with a health decision that would benefit from getting a second opinion.  

Quick? Or informed? The lack of happiness you experience in looking at all the menu options -- when it comes to health care -- may be worth it in the long run, if you can stand it.

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Side Effects of Your Drugs? What You May Not Have Been Told

For every drug you take, the benefits should always outweigh the risks.

Every medication has at least a few potential side effects, some mild, some not so mild, and sometimes others that can be serious. Most side effects vary from person to person. So you can't always be sure what you'll experience. But it is extremely helpful to know what you should be on the look-out for. 

New research suggests that many physicians aren't  aware of the possible harmful effects of the medications they recommend to patients.

A study just published in the Journal of General Internal Medicine found that although drug company representatives give family doctors and internists almost no information about potential side effects, physicians were likely to prescribe the drugs anyway. 

The research looked at questionnaires given to a random sample of 255 doctors in the U.S., Canada and France.  The physicians completed questionnaires right after the sales representatives left their offices, describing what was discussed. Although laws in all three countries require sales representatives to review the pros and cons of drugs they're promoting, the cons weren't mentioned in 59% of the salesperson-physician encounters. 

Serious side effects were only brought up in 6% of the conversations, although 57% of the drugs discussed were associated with serious potential problems, requiring what is known as "black box" labeling on the medication containers or product inserts designed to alert physicians and patients alike to the risks. 

Health benefits were discussed almost  twice as often as were side effects. Yet  physicians rated the quality of the information provided as good, and expressed a willingness to increase their prescriptions of the drugs discussed about  two-thirds of the time.

A  survey in 2009 that that 85% of doctors view pharmaceutical sales representatives as their first source of information about new drugs on the market.

You might just assume physicians would read the product literature associated with the medications they prescribe and make sure they fully understand a drug's effects before they recommend it for you. This research suggests that is not necessarily the case.

What to do?

• Any time your healthcare provider recommends a drug for you, ask about the drug's common and less common side effects and how you personally might fare on the medication. In some cases, after talking with you doctor, you may choose to stay on the drug, perhaps with a lower dose or frequency. Other times, you might be switched to something else, or even decide to not treat your condition with this medication for awhile.

• Before you get the medication from your pharmacy, take a moment to look it up on the Internet, at sites such as AdverseEvents.com,  drugs.com,  and MedlinePlus .Review the side effects and check potential interactions with any other medications you are taking.

• If you have any questions, contact your doctor or discuss your questions with your pharmacist.

• If you have any symptoms that are worrisome to you or experience anything that affects, for example, your ability to drive or operate other heavy machinery, any vision changes, dizziness, severe headache, nausea, vomiting, difficulty breathing or swallowing, severe diarrhea or skin changes such as itching or a rash, contact your doctor immediately and stop taking the medication until you talk with him or her. If you cannot reach your healthcare provider seek help from an emergency department or urgent care center.

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When a Biopsy is Negative, Celebrate Cautiously

It's the phone call everybody wants to get. 

"Your biopsy was negative." Time to celebrate? Yes. 

But celebrate cautiously.

Sometimes what comes back as a benign (non-cancerous) biopsy may be a false negative. In other words, the portion that was taken to study under a microscope did not capture the diseased tissue. 

Here's a cautionary tale. A year and a half ago, I noticed a small, almost invisible scab on the top of my head. I figured I had hit my scalp against something, but realized a week or two later that the problem wasn't going away. I went to the dermatologist, had it biopsied, and it was benign. Easily removed. Bravo. Done.

About six weeks ago, the scab was back. 

I went to my "health care" file folder and pulled out my copy of the biopsy report on the previous problem. (Another tip: always get a copy of any report about a biopsy, surgery or procedure. You never know when you'll want to have it handy). Yes, my memory had served me well. It had been benign. Nothing to worry about.

But, thinking about it, I knew it wasn't normal to see the scab back again, so off I went to the doctor again. Another biopsy. 

This time it showed two different kinds of non-melamona skin cancers, which needed to be removed surgically. 

The moral of the story is simple: if signs or symptoms of any sort return after a reassuring biopsy, get your situation re-examined. 

Sometimes, right from the start, you might want to ask the physician to take two biopsies, from two different parts of a suspicious something, just to provide additional analytical rigor. You can even ask to have each sample sent to a different lab or pathologist, if you want to be exceedingly careful. In some cases, such as prostate cancer, multiple biopsies are done routinely, but not so much in other situations, such as small skin problems. 

The bottom line: Whenever you get a biopsy with good results, don't hesitate to ask your physician how you can monitor the area yourself and what signs should cause you to come back in for another look. 

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