Vol. 222 December 1, 2019 Annual List of Hazardous Toys

December 1, 2019

World Against Toys Causing Hazards (W.A.T.C.H.) has just published  its 2019 “Top 10”  list of most dangerous toy “nominees” in time for holiday buying. (I’m not sure an actual vote is ever taken, but they still call them “nominees”) . As in the previous 47 years the choking hazards of small parts, the presence of long strings or wires with strangulation potential, and potential eye injuries from flying parts caused several toys to be listed. Here is a summary of some of the more interesting toys . Pictures of the toys and more details are available on the WATCH website.

NERF Ultra One– “furthest flying NERF dart ever” ; 120 feet – potential eye injuries
YETI – a”cuddle” toy with easily pulled out long hairs that can be ingested or cause ligatures around fingers, toes, and other protuberant organs.
NICKELODEON FROZEN TREAT SLIME – Made with a variety of hazardous chemicals, it has a DO NOT EAT label on the package, but looks like mint chocolate chip, berry smoothies, and soft serve.

 

 

 

 

 

 


ANSTOY ELECTRIC TOY GUN-

(no further comment necessary on this realistic looking submachine gun)

 

POWER RANGERS ELECTRONIC CHEETAH CLAW– “Use the strength of the claw to take on enemies. . . but don’t hit or swing at people.”

WATCH added an additional caution about buying toys online, which they predict to be about 60% of total toys bought this holiday season. An analysis of over 2000 toys on Amazon revealed that 64% did not have the choking hazard warnings that the same toys did on Target.com.

The independent federal Consumer Product Safety Commission logged 257,000 toy-related injuries in 2017. “One child is treated in a U.S. emergency room every 3 minutes for a toy-related injury.” (That child must be really accident-prone and  very tired – drum roll of rim shots!) In the last two years over 1.2 million toy units were recalled after lead paint poisonings, lacerations, or strangulations. However, toys are getting safer. In 2008 the CSPC issued 172 recalls (not units) while there were only 12 recalls in 2019.

The Toy Association, a toy industry trade group that represents most of the toy makers named on the list, dismissed the annual list as misleading. It suggests parents should always purchase toys from reputable stores and online sellers. “By law, all toys sold in the United States must meet 100+ rigorous safety tests and standards,” the organization said in a written statement. That sounds a lot like Dan Ackroyd as the toy salesman pitching a bag of broken glass on a classic SNL Christmas skit. (Ackroyd’s comeback was a pitch to buy an accompanying bag of toy bandaids.)

Additional serious hazards for small children this holiday season are liquid nicotine and marijuana pods for vaping devices.

Delivered in high doses, nicotine can be lethal.  Exposure to liquid nicotine found in e-cigarettes has resulted in thousands of calls to poison control centers in recent years.  Liquid nicotine poisoning can occur in three ways: by ingestion, inhalation, or absorption through the skin or eyes.  For small children, coming into contact with even a small amount of a highly-concentrated liquid nicotine product can be fatal.

The CSPC is responsible for enforcing a key provision of the Child Nicotine Poisoning Prevention Act of 2015 that requires any nicotine provided in a liquid nicotine container sold, offered for sale, manufactured for sale, distributed in commerce, or imported into the United States to be in “special packaging”.  This packaging, in layman’s terms, must be designed to prevent children from accidentally accessing and ingesting liquid nicotine, and must restrict the flow of liquid nicotine under specific conditions.

Though not lethal, yet, concentrated pods of marijuana for vaping devices if ingested by toddlers can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble if ingested by toddlers.

 


Vol. 221 November 15, 2019 “Cassandra Speaking of Climate Change “

November 15, 2019

Cassandra: one who speaks a prophecy that no one heeds.

A friend of mine (actually his wife) was cleaning out his collection of many years of books, cowboy boots, framed certificates, and other cherished stuff when he found three 1996 pamphlets published by The Worldwatch Institute, an independent, nonprofit environmental research organization in Washington, DC. founded in 1974 and still going strong.  My friend thought I might be interested in them.  One of them, “Climate of Hope: New Strategies for Stabilizing the World’s Atmosphere” published in June 1996, prompted me to think about what were their predictions and did they come true? That is the subject of today’s blog.

Quotes directly from Worldwatch Paper #130 “Climate of Hope” June 1996:

  • “Climate change is likely to be erratic, disruptive, and unpredictable. . . The incidence of floods, droughts, fires and heat outbreaks is expected to increase in some regions.”
  • “Recent changes in global climate trends are almost certainly related to the rapid buildup of greenhouse gases.”
  • “Carbon dioxide is a greenhouse gas, letting in visible light from the sun but trapping heat near the earth’s surface.”
  • “Since carbon dioxide is a virtually inevitable product of fossil-fuel-based energy system, efforts to stabilize the climate will at some point have to require a fundamental revamping of that system. Exactly how to do this and at what cost have been subjects of considerable uncertainty and vehement debate.”

There are several greenhouse gases, including methane (hence the “target” on the backs of farting cows) and chlorofluorocarbons (CFCs, HFCs) which are manmade chemicals that have been largely phased out because of their depletion of the ozone layer. Sulfur gas, also from fossil fuel burning, is not a greenhouse gas but does produce acid rain. Stringent emission standards in the 90’s by most industrialized countries have significantly reduced the amount of sulfates in the atmosphere. Carbon dioxide is the largest greenhouse gas by volume in our atmosphere, and carbon dioxide level measurement have become a standard proxy for predicting world-wide temperature increases.

Prior to the industrial revolution in the 1800’s carbon dioxide levels in the atmosphere hovered just below 300 parts per million (ppm). In 1996 the level was 360 ppm. In order to slow global warming the carbon dioxide level will have to be below 500 ppm. Our world-wide carbon dioxide level is currently 420 ppm. “A 450 ppm target means cutting emissions by more than half by 2050. A level of 500 ppm, which would accelerate global warming, could be reached by 2050 if carbon dioxide emissions are not reduced.” (1996) Because carbon dioxide is a “long-lasting” gas in our atmosphere it’s effect on global temperature is cumulative over decades, so that if we (the world) wanted to return to 1996 levels we (the world) would have to go to zero carbon dioxide emissions, an impossible task.

More words from the 1996 Cassandra:
“We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.”

Remember, these words are from 1996. As Yogi Berra said: “It’s like deja vu all over again.”

Meanwhile, as Stephen Colbert says occasionally,
Cause of the Vaping Lung Injury
In my last blog I reviewed a pathological study of lung tissue in 17 patients with the vaping related lung injury which showed no damages indicative of lipoid or oil-caused pathology. The researchers concluded that vitamin E oil was not the culprit, and that the lung injury was similar to that seen from inhalation of a toxic gas and not the inhalation of oil. They did not know what that “toxic gas” was.  The CDC has just released a study of 29 patients suggesting that the offending agent might actually be inhaled vitamin E acetate because they found that in the injured lungs. They also admitted that other unknown agents might be causing the injury.
Meanwhile, hospitals are reporting an increase (one a week in some places) of a hyperemesis syndrome, (persistent, prolonged vomiting), in heavy users of recreational marijuana. First identified in 2004 it can be difficult to diagnose as several other causes have to be ruled out with x-rays and lab tests, but it is increasing in states that have legalized recreational marijuana.

 

 


Vol. 220 November 1, 2019 Update on Vaping Lung Disease, Medical Marijuana, and CBD.

November 1, 2019

“We thought vaping was safe, and it wasn’t. . . it isn’t.”
-Charlie Baker, Massachusetts Governor, justifying his state-wide 3 month ban of vaping

 

What Causes Vaping Associated Lung Disease?
The plot thickens as to the cause of the nation-wide epidemic of vaping-associated lung injuries, including deaths. Our immediate “conventional wisdom” was that it was probably related to inhalation of the vitamin E oil  used to cut the black market THC. (You may have read it here first) Oil inhalation associated injury is now doubted after examination of lung biopsy tissue and/or autopsy specimens from 17 patients. Pathologists from the Mayo Clinic in Scottsdale, Arizona found no evidence of inhaled oil or the expected microscopic hallmarks of lipoid pneumonia in the lungs of patients with the lung injury after vaping. What they did find was evidence suggesting a chemical “burn” or reaction to a toxic gas. There was no sign of an immune response (like an allergic reaction) that would have suggested that only certain individuals could develop the lung injury disease. The researchers did not speculate as to what could have caused the injury, except they are clear that it doesn’t appear that vitamin E oil is the culprit. It puts us back to considering all possibilities: something added to black market vaping material (both THC and nicotine vapers have been injured or killed), noxious gas produced by the device itself, or a combination of the two. This lung injury epidemic began in August 2019 despite several previous years of vaping use, so “something has changed”.  Stay tuned, and don’t vape.

Are There Any Benefits of Medical Marijuana?
Despite the many claims of the benefits of medical marijuana for a variety of conditions, current scientific evidence supports benefits in only three situations: 1. reduce nausea and vomiting after receiving chemotherapy, 2. subjective decrease of spasticity symptoms in multiple sclerosis, and 3. improve chronic pain in adults. The benefit seen in a very rare form of childhood epilepsy is due to CBD alone, not THC. The old idea of benefit in glaucoma treatment was disproven a while back (remember folks? you may have first read it here). A current controlled study of the benefits of medical marijuana is underway at MGH and one of its researchers gave a interim report of their early findings at a conference I attended last week.

The researchers are attempting to do a randomized study of the benefits of medical marijuana in patients 18-55 yo.already holding a medical marijuana card (obtained from a marijuana-use certifying physician for $300 for a single visit). Neither of the researchers, and, in fact, not one of all the MGH physicians are marijuana-use certifying physicians. Since these patients view the marijuana as a treatment for their condition it is unethical to randomize some into a control group who would receive none. Since the clinic can not handle all comers at once they assigned about a third of the patients to a 3 month waiting list for their medical marijuana card. Tests and questions of both the waiting list patients (“control group”) and the patients receiving medical marijuana immediately (“treatment group”) should reveal reveal any benefits or harms from medical marijuana use. A previous study showed that obtaining a medical marijuana card caused holders to double the number of days per month that they used marijuana for their symptoms (from 7 1/2  to 15 days per month).

Since the researchers (along with everyone else) don’t really know what exactly is in the products purchased at a marijuana dispensary, they test for 11 different cannabis metabolites (including CBD) in the patient’s urine each visit. Preliminary data on 84 patients reveals minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product (a “marketing plus” since CBD is touted to reduce adverse effects of THC), one third of the patients had NO detectable CBD in their urine!

Spoiler alert: Today’s cannabis is not your father’s kind of cannabis. Joints at Woodstock had about 1-2% THC. Today the average joint has 6-12% THC. A new edible form of cannabis oil or syrup, called a “dab”, can be 60-90% THC. So “a little dab could really do you.”

What About CBD?
We know even less about the medical benefits of CBD despite the many advertising claims, wide spread ease of purchase, and Gronk’s testimonial endorsement. Cannabis contains over 200 cannabinoids. CBD is one and THC is another. Stay tuned. (Remember, you may have first read it here.)


Vol. 218 September 15, 2019 Vaping and Fatal Pneumonia

September 15, 2019

“The rise in vaping-associated illness is a frightening public health phenomenon.”

– Andrew Cuomo, NewYork Governor

 

Severe pneumonia in over 400 people, including 10 deaths, in 36 states have been associated with vaping certain products. The CDC is investigating the phenomenon as a mysterious, previously unrecognized epidemic. Patients from 18 to 88 years of age have been arriving at Emergency Rooms with severe shortness of breath, cough, little or no fever, and a chest Xray with markedly abnormal diffuse infiltrates. Blood cultures show no bacteria, and the response to the usual antibiotics is sluggish or absent. Some patients require intubation and artificial ventilation in order to maintain oxygenation of their blood. A few die. All have a history of vaping, most often using flavored vaping solutions purchased “on the street” or over the internet, i.e. not from licensed vape shops.

The speculation at this point is that flavored vaping solutions have additives that are causing this illness.  The current focus is on Vitamin E oil, added to flavored vaping solutions as a thickening agent. Vitamin E is well recognized as a beneficial skin emollient and an oral nutrient supplement, so it sounds harmless and enjoys a “good-health” reputation. It is inexpensive and readily available, so is a “logical” additive for cheaper, unlicensed vaping solutions sold on the black market (“street-made”) and the internet. The street vendors use the cheaper additives to cut the expensive THC oil and make more profit per vaping cartridge.

In an e-cigarette the Vitamin E oil is heated up and vaporized by a battery-fed hot wire, and the vapor is inhaled. As the temperature of the Vitamin E oil vapor lowers to the normal body temperature of 98.6 degrees Fahrenheit the Vitamin E vapor in the lungs reverts to its liquid form, oil. Any form of oil is extremely toxic to lung tissue. Just ask any physician who has dealt with a patient with oil-aspiration pneumonia, sometimes called “lipoid pneumonia“. The first case report of lipoid pneumonia after vaping was actually reported in 2015 in the journal Chest  as a unique, interesting, never-before seen case of a 31 yo. West Virginian woman who required intubation in the ICU after presenting to the ER in severe respiratory distress after vaping.

There are so many additives in vaping solutions that it is not absolutely certain that Vitamin E oil is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% Vitamin E oil!  A 2015 Harvard study that tested 51 of 7,000 vaping solutions found Vitamin E oil in all the flavored ones, and it commented on the potential dangers of inhaling flavored vaping solutions. None of the vaping solutions containing “only” nicotine  or marijuana (THC) contained Vitamin E oil. By the way, the FDA and the various state cannabis commissions have NO idea of the ingredients and additives in vaping solutions. There are currently NO regulations requiring the listing of vaping solution ingredients, even those sold in licensed vape shops. “The cannabis commission does not regulate the ingredients in licensed marijuana stores’ vape cartridges. . . Licensed producers can source their ingredients from anywhere.”

As an aside, this reminds me of a story told by my cousin, a biochemical Ph.D candidate in the 1960’s researching how chlorophyll (the green substance) carried on photosynthesis. In his chromatographic analysis of all sorts of substances, including tobacco, he determined that Marlboro cigarettes had no tobacco in them. They appeared to be made of cabbage leaves infused with nicotine. Incensed (he was a smoker), he wrote an emphatic letter to the company documenting his findings and scolding them for false advertising.. The company’s response was a polite letter pointing out that at no time did they claim in their ads that their cigarettes had any tobacco in them, that they merely promised a smooth taste  . . .and “good luck on your quest to synthesize an artificial chlorophyll.”

The CDC is foraging ahead aggressively with detailed investigations, state legislatures are composing all sorts of ingredient disclosure laws for vaping manufacturers, and, I am sure, many personal injury lawyers are trolling for potentially lucrative suits. In the meantime, I think it would be the better part of valor if everyone stopped vaping until the dust . . . er . . . the vapor settles. Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”


Vol. 217 September 1, 2019 Understanding Medical News of Famous People

September 2, 2019

David Andrews, veteran center for the New England Patriots, and Ruth Bader Ginsburg, veteran Supreme Court Justice, have both been in recent newspaper headlines (in different sections of the paper, of course) due to their new medical diagnoses, “clots in the lung” for Andrews and “pancreatic cancer” for RBG. Most articles devote significant space to speculation about their prognoses, i.e. when can Andrews return to play in the NFL and will Ginsburg outlast Trump’s presidency? Why do the answers seem so elusive, and almost always end up with “it depends”?

 

“Clots in the lung” are pieces of blood clots that travel through the blood steam after breaking off from blood clots in the legs (deep vein thrombosis or DVT). In the lungs the clots can clog or drastically slow down the flow of blood through lung vessels and is called pulmonary embolism (PE). PE may often produce no symptoms or cause chest pain, cough, difficulty breathing, and sudden death.

PE is treated with so-called “blood thinners” aiming to reduce the risk of more emboli traveling to the lungs. Neither of the two classes of anti-coagulation drugs actually thin the blood. Both interfere with the multiple steps of coagulation needed to form a clot, thus reducing the chance of more pieces of clot breaking off and traveling to the lungs.

How long is drug treatment necessary? It depends. The shortest duration of 3-6 months is recommended for “provoked” PE, an embolism from a leg or pelvic clot provoked by an injury, surgery, infection, cancer, or other recognizable event. An “unprovoked” PE, one without a recognizable event, is usually treated for longer periods.

It is probable that Andrews’ PE was related to a football injury, a “provoked” PE, so that anti-coagulation treatment will last for at least 3-6 months. Hence he is out for the season, since it would be dangerous for him to play football with an intentionally defective blood clotting mechanism. If his PE was not the result of an injury, then it was “unprovoked” and treatment duration may be even longer.

RBG just completed treatment for her third bout of cancer. She was treated for colon cancer in 1999, “early” pancreatic cancer in 2009, and a cancer in her lung was surgically removed in December of 2018.  This recent treatment consisted of 3 weeks of highly focussed radiation to a small malignant mass in the part of the pancreas (the “head”) that surrounds the bile duct that goes from the liver to the small intestine. A stent was placed in the bile duct presumably because even this highly focussed radiation could cause the duct to swell and obstruct resulting in her becoming jaundiced. Her doctors did not identify the mass as colon, lung, or pancreatic cancer, but reported that it was localized with “no evidence of cancer elsewhere”.

That last bit of news is significant since the prognosis of pancreatic cancer depends on the stage of disease, from 1 to 4. Stage 1, local disease, has a 5 year survival rate of 12-14% while Stage 4, widespread disease, has a 5 year survival rate of 1%. Survival rates are statistics based on the outcomes of hundreds of patients and can not be reliably applied to an individual patient. RBG has especially proved that herself. In a recent interview RBG remarked that “a certain Senator who predicted my early demise after my 2009 diagnosis of pancreatic cancer is now dead himself while I’m still alive.”

Because of the fallacy of applying the mortality statistics of hundreds of patients to an individual, the honest doctor realizes that a prognosis often can not be given accurately. That knowledge is also colored with the emotion of difficulty breaking bad news. One study showed that only about 37% of oncologists were able to give an “honest” prognosis to a cancer patient under treatment. When the doctor did give a prognosis, it was often overly optimistic. 

So, what is the prognosis for Andrews and Ginsburg? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistic outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows what will happen. The doctors may guess, but they don’t know either.


Vol. 216 July 1, 2019 Public Opinion About High Health Care Costs

June 30, 2019

‘TIS THE SEASON FOR POLS AND POLLS

 

As the presidential election summer season heats up with Democrat’s TV food fights and President Trump’s relentless echoes of 2016 campaign rhetoric, the frequency of public opinion polls on political issues and candidates is increasing. What do polls show about what people think about health care costs? The New England Journal of Medicine just published an analysis by three authors of 14 public opinion polls on health care costs done in 2018-2019 (1)

Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019 (second only to “strengthening the economy” at 70%).

About 90 % of respondents picked the following priorities as “extremely important”:
Reduce prescription drug prices
Reduce the overall cost of healthcare
Do not cut Medicare insurance benefits
Maintain insurance coverage for pre-existing conditions.

Half of respondents reported that health care costs had “actually affected their household a lot”.
40% were “not satisfied” with how much they had to pay for health care.

Why did respondents think that health care costs were so high?
drug companies charge too much …………. 78%
hospitals charge too much ……………………. 71%
Insurance companies charge too much ….. 71%
new drugs, treatments, and technology…….62%

The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.

“At this level, unnecessary health care costs and waste exceed the 2009 budget for the Department of Defense by more than $100 billion (OMB, 2010). Health care waste also amounts to more than 1.5 times the nation’s total infrastructure investment in 2004, including roads, railroads, aviation, drinking water, telecommunications, and other structures. To put these estimates in the context of health care expenditures, the estimated redirected funds could provide health insurance coverage for more than 150 million workers (including both employer and employee contributions), which exceeds the 2009 civilian labor force. And the total projected amounts could pay the salaries of all of the nation’s first response personnel, including firefighters, police officers, and emergency medical technicians, for more than 12 years.” (2)

How did people think we could reduce healthcare cost?
Nearly 90% want the federal government to negotiate drug prices for Medicare
65% want the government to limit charges by hospitals and health professionals
65% want to allow 50-64 year olds to buy into Medicare
52% support “Medicare For All” with little or no private insurance.

Which government?
State 50%  (favored by 60% of Republicans)
Federal 50%  (favored by 70% of democrats)

By what mechanism?
Private insurance competition  (60% of Republicans)
Government insurance program (65% of Democrats)

A majority agreed on two unacceptable ways to reduce costs?

  1. Restrict access to treatments and prescription drugs via “expert opinion” of cost/benefit ratios.
  2. Tax incentives to individuals to buy high-deductible insurance plans.

Only 25% of the public polled were concerned that Medicare would run out of money in 10 years, i.e. little concern about the aggregate cost of health care. Most considered the cost problem as one of high prices rather than of over utilization.
Also, the public is highly skeptical that ANY approach will greatly reduce healthcare prices.

So, despite the consensus that reducing health care costs should be a high priority for President Trump and Congress, there is an obvious partisan divide about how to do it; a partisan divide that continues to make us (the U.S.) unique as the only developed nation lacking universal health care insurance for its people.

References
1. NEJM 380;26 June 27, 2019
2. Best Care At Lower Cost, National Academy of Medicine, Institute of Medicine, 2013


Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.


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