Coordination of Care

by Charles Vega, MD

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    00:01 I'm gonna discuss coordination of care with you today.

    00:04 And this is something that's increasingly important in health care overall.

    00:08 We as physicians should recognize that we can't do everything for our patients.

    00:13 They have too many needs and there's too much of care that's decided that goes beyond our patient-physician encounter.

    00:20 That has a significant impact on the patient's life.

    00:23 So therefore, a team of care is really, really important.

    00:26 And putting the patient at the center of that care is critical.

    00:30 So we'll be talking about why that's important.

    00:34 And we'll be talking about specifically about the impact of medical errors.

    00:37 I'm gonna walk through a case which will highlight some specific errors in terms of medical management.

    00:44 And how to avoid drug-drug interactions which is one of the most avoidable yet important forms of medical errors.

    00:51 And then we'll be talking about some of the results of using a team based approach to care.

    00:55 So this is really a primer but hopefully it gives you some impactful information that you can use.

    01:00 And it's starts with the Institute of Medicine "To Err is Human" report.

    01:04 And this came about some time ago.

    01:06 But still is a landmark study that found that overall the rate of adverse events, complicating hospital admissions in the United States were 3%.

    01:14 If you look at all the hospital admissions that's millions of patients affected.

    01:18 Half of these errors were preventable.

    01:21 So now there's this emphasis on preventing deep venous thrombosis or pneumonia or urinary tract infection.

    01:29 It really came from this report.

    01:31 And that's why we're really trying to emphasize quality of care and getting the care right before the patient leaves the hospital.

    01:37 Coordinating care once they return to home so that we can avoid adverse events.

    01:42 Because the events are severe.

    01:44 It's not just getting urinary tract infection or even a deep venous thrombosis.

    01:49 It's estimated that in this study 44,000 and 98,000 individuals died every year due to medical errors specifically.

    01:58 Now, an update to this data in 2016, looking at a broad spectrum of diagnosis and a database of hospital discharges estimates that actually the number of people who die due to medical errors may be exceed 250,000 per year.

    02:16 And this is a real crisis.

    02:17 It's like a small city dying every year just due to medical errors alone.

    02:22 If validated this would make medical errors the third leading cause of death in the United States after heart disease and cancer.

    02:30 In terms of overall medical cost, in 2008, 19.5 billion was lost directly in terms of medical errors.

    02:39 Most of that was due to the direct medical cost, nd a lot of times that was in-patient related.

    02:44 But if we estimate that, you know, for every quality adjusted life-year for productivity, you can estimate there's 75,000 to a 100,000 there, and we take that conservative estimate of 98,000 deaths due to medical errors every year.

    02:58 That means that in addition to that direct medical cost of 19.5 billion, there's also 73 to 98 billion dollars lost due to lost productivity in those deaths as well.

    03:10 So a significant cost in terms of mortality and morbidity but also in terms of economics as well.

    03:16 So let's look at adverse drug events.

    03:20 And this is a review of 29 studies.

    03:23 They found the prevalence of such events about 15 events per 1,000 person-months.

    03:28 And over 5 events per 1,000 person-months were preventable.

    03:33 Most of these events were fairly severe.

    03:37 They required admission to the hospital.

    03:38 And they're actually more serious than unpreventable events.

    03:42 Now, what's the take home that I can give you about like, how to look at your drugs, and minimizes the clinical pearl.

    03:49 Eighty six percent of these preventable events were due to only three classes of drugs.

    03:55 So these are the ones you really wanna watch out as you're prescribing.

    03:57 Cardiovascular drugs, hypoglycemic drugs and analgesics.

    04:01 And what were the effect to the systems, 77% at a time it was due to central nervous system effects.

    04:08 So this is particularly for drugs like hypoglycemic drugs and cardiovascular drugs.

    04:13 Getting dizzy, passing out, falling, breaking a hip, breaking a shoulder, getting an intracranial bleed.

    04:19 So that's number one.

    04:21 Two, the cardiovascular drugs...

    04:24 actually all three classes can contribute to renal/electrolyte abnormalities.

    04:28 So acute kidney injury, hyper and hypokalemia.

    04:32 Hyper and hypoglycemia.

    04:34 These are the things to watch out for as well.

    04:36 And then why is gastrointestinal events on the list? It's because analgesics can promote a high rate of GI bleeding.

    04:45 And there's other, you know, less serious events like nausea and vomiting.

    04:50 But really watching, the use of, particularly nonsteroidal anti-inflammatory drugs and the risk for GI bleeding is very important.

    04:57 So we're gonna highlight some of those issues with the case.

    05:00 And this is a different case.

    05:01 We're not looking to find a diagnosis here, that's gonna be fairly obvious.

    05:05 What I really want you to focus on is, you know, how is this patient currently being treated for a litany of health disorders which I see every day in my clinic.

    05:15 So this is a 68-year-old.

    05:17 Her main complaint is knee pain.

    05:18 It's growing worse with activity over the past three months.

    05:20 And she's disabled.

    05:23 She can't walk more than 3 blocks.

    05:24 Now, this history may seem like a lot but it's very common in my practice.

    05:29 And this disease is very, very commonly are co-morbid in the same patients.

    05:34 So she has coronary artery disease with a stent placement two years ago.

    05:38 She has type 2 diabetes, hypertension, hyperlipidemia as well as chronic kidney disease at stage 3.

    05:45 And this is why I wanna spend a little time.

    05:47 Her list of medications includes aspirin, clopidogrel, sitagliptin, insulin glargine, metoprotol, lisinopril, atorvastatin, omeprazole.

    05:59 Something called APAP/hydrocodone.

    06:02 And that's a lot--that's a lot of medications.

    06:04 In fact we know that people over 65 years of age, about half of them are taking at least 5 different drugs.

    06:10 So the chance for interactions therefore, very high.

    06:13 But wait, we're actually not done.

    06:16 Because that's the ones you prescribed.

    06:18 And that you probably I hope know about.

    06:21 She's also taking a bunch of as-needed medications which maybe you didn't prescribed.

    06:25 She's selecting to take them on their own or they're over the counter.

    06:28 And they include Ibuprofen, naproxen, acetaminophen, Vitamin E, beta carotene and ginseng.

    06:35 So let's take a look at that list for a second and tell me what's wrong.

    06:39 And then I'll contribute my part.

    06:43 I could tell you that I don't see a lot of problems with her diabetes care.

    06:48 She's on the right drugs for her coronary artery disease.

    06:53 I see a beta blocker in there, an ACE inhibitor, a statin and aspirin.

    06:57 But then I look at she's on aspirin and clopidrogel.

    07:01 That might have been a good idea, dual anti-platelet therapy.

    07:04 Even up to a year after a stent placement.

    07:06 But now it's putting a risk for bleeding.

    07:09 Because we know when you use two agents together, the risk of bleeding is well elevated versus one agent alone.

    07:14 In addition, she's taking Ibuprofen and naproxen further bleeding risk.

    07:19 So I'm really worried about this older women getting GI bleeding particularly because she's on omeprazole.

    07:25 Why is she taking that? I don't know.

    07:28 I don't know why she is taking omeprazole.

    07:30 Maybe she had a history of GI bleed though.

    07:33 That's the reason people take it over time.

    07:35 And if that's the case then her risk is very elevated for a gastrointestinal bleed.

    07:41 Okay, let's pull back again for a second.

    07:43 So the first thing I would do is got to get rid of the NSAIDs and really try to limit her probably to one antiplatelet agent, aspirin or clopidrogel.

    07:52 Second, she's taking a large drug for pain, the NSAIDs I mentioned and she's also taking acetaminophen.

    07:59 Plus, she has this APAP/hydrocodone.

    08:01 Does she know what APAP is? Do you? APAP is acetaminophen.

    08:07 Paracetamol.

    08:08 It's got a bunch of different names.

    08:10 And the good news is they're doing away with labeling where it doesn't say in the United States acetaminophen directly.

    08:16 So people can know that the product that they're taking for their upper respiratory infection and for their pain, and for their headaches is all the same product.

    08:25 Because acetaminophen is still the number one cause of acute liver injury in the United States, and acetaminophen overdose.

    08:34 About half of those cases of acetaminophen overdose are intentional, suicidal gesture or suicide attempt.

    08:41 But half are unintentional.

    08:43 And a lot of times it's because the patients don't realize all the forms of acetaminophen they're taking.

    08:47 So she probably should stop taking these, the APAP/hydrocodone.

    08:51 Take that off because of the opioid in it.

    08:53 And just leave her on acetaminophen alone much cleaner, lower risk of liver toxicity associated with that.

    09:00 Other things, she's taking a few different agents that therefore are considered, you know, vitamins or consider some kind of alternative therapy or herbal therapy.

    09:12 They're not really been associated with improving any of the outcome she has.

    09:17 Ginseng has been associated with some risk of bleeding.

    09:20 Beta carotene in excess has been associated with a risk of lung cancer.

    09:23 And vitamin E can actually be a pro-oxidant if given in overdose.

    09:28 It says important to assess what are those really are important, and the doses that she's using and try to get her on something that is at least safe.

    09:37 And maybe just to help clean up her list which is currently sitting at somewhere around 12 different drugs.

    09:43 Maybe taking those off because you really wanna focus on what she needs to be taking now.

    09:49 In our final diagnosis, arthritis to the knees, you're probably not, you know, she has an effusion.

    09:55 She has joint line tenderness.

    09:57 You know, you get an X-ray that reveals osteoarthritis.

    10:00 And that's interesting.

    10:01 It's interesting to diagnose, and we can try to help her with her osteoarthritis.

    10:05 But again it goes back to this list of medications.

    10:09 That's the first thing I'm gonna focus on, in terms of keeping this patient safe.

    10:13 And not letting her become one of those statistics, where she has to go to the hospital, or she even dies due to drug errors.

    10:20 So can case coordination help with these kinds of complicated cases? This is a systematic review of 36 randomize trials.

    10:27 A total of nearly 7,500 patients.

    10:29 The focus was on complex patients.

    10:31 So a lot of these teams will focus on severe diagnosis such as heart failure is a popular one.

    10:39 Chronic obstructed pulmonary disease.

    10:41 Diabetes with complications.

    10:44 And most used case management along with some approach to team base care, as well as empowering the patient.

    10:51 And they can't be left out.

    10:52 They are actually the most important part of the healthcare team is the patient him or herself.

    10:58 And so therefore, empowering them and giving them skills and knowledge so that they can succeed in managing their own illness is critically important.

    11:05 What were some of the outcomes they found in the systematic review? First of all, patients went in the hospital less.

    11:10 So the risk of hospitalization decline almost 20% versus usual care.

    11:15 They also found that emergency department visits were reduced as well.

    11:20 Now, primary care visits increased.

    11:23 Emergency department visits decreased.

    11:26 And that's actually a good thing.

    11:27 That's part of being team based cares trying to get patients, particularly high risk patients into outpatient care more readily.

    11:34 And also using things like electronic communication or patient diaries or home visits to really get the patient's information to the providers in a more efficient way, than waiting just three weeks for your next appointment.

    11:50 Because sometimes three weeks is just too long.

    11:51 The team base care was effective for chronic medical illness, but not mental illness.

    11:58 There's a couple of gaps in team base care.

    12:00 One is mental illness.

    12:02 The other is really in preventing readmission for very high risk patients.

    12:07 So the patients who come in with six exacerbations of heart failure or COPD every year, case coordination doesn't necessarily improve their risk of re-hospitalization.

    12:17 So it's those really re-clustering cases that have proven difficult and we're still trying to find ways to provide the best care and keep those patients out of hospital.

    12:26 As I mentioned, it didn't reduce outpatient visits, but that's okay.

    12:30 Part of a care plan is to increase outpatient visits.

    12:33 It didn't change the subsequent lengths of hospital stay either.

    12:37 So with that hopefully you have some idea about particularly the impact of medication errors, but the broad impact of medical errors overall on our society.

    12:48 And then you have some, some now, some strong desire to be part of a care team that can help reduce those errors.

    12:57 Thank you.

    About the Lecture

    The lecture Coordination of Care by Charles Vega, MD is from the course Introduction to Family Medicine. It contains the following chapters:

    • Coordination of Care
    • Typical Case of Familiy Medicine

    Included Quiz Questions

    1. Decreased emergency room visits
    2. Decreased primary care visits
    3. Decreased rate of frequency of re-hospitalizations
    4. Decreased adverse events in mental illness
    5. Decreased length of hospitalizations
    1. The patient
    2. The social worker
    3. The medical assistant
    4. The physician
    5. The home health care giver
    1. About 50%
    2. 10%
    3. 3%
    4. Nearly 25%
    5. Nearly all
    1. Medical errors are the 3ʳᵈ leading cause of death in the U.S. after cancer and heart disease
    2. Medical errors account for over 50% of annual medical costs in the country
    3. Medical errors are the number one cause of death in the U.S.A.
    4. Medical errors account for the majority of annual medical costs in the country
    1. Early hospital discharge
    2. Co-ordination of patient centered care with a multidisciplinary team
    3. Medication list review at primary care visits and prior to hospital discharge
    4. Deep vein thrombosis prophylaxis during hospitalization
    5. Early urinary catheter removal post-operatively
    1. Cardiovascular drugs, hypoglycemic drugs, and analgesics
    2. Analgesics, antibiotics, and hypertensive medications
    3. Hypoglycemic drugs, analgesics, and over the counter herbal remedies
    4. Cardiovascular drugs, antibiotics, and herbal remedies
    5. Vaccinations, antibiotics, and anti-cholesterol medications

    Author of lecture Coordination of Care

     Charles Vega, MD

    Charles Vega, MD

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