Understanding Sleep Apnea

With the rising obesity epidemic in America, we are going to see more and more people who have sleep apnea. When casually used, the term 'sleep apnea' refers to the obstructive sleep apnea. In OSA, brain sends signal to breath, the chest moves up and down, but due to obstruction in the back of throat, there is reduced air flowing in to the lungs. There is another type of apnea known as central sleep apnea- that is when there the brain does not send signal to breath, and there is no chest effort and no flow of air to the lungs. When patients have both obstructive and central sleep apnea, then it is known as complex sleep apnea.

Even though we associate OSA with obesity, not all patients who are obese will have sleep apnea, and not all patients with OSA are obese. The other two factors besides BMI that are responsible for OSA include- upper airway anatomy and muscle tone.

Upper airway structure that results in crowded back of the throat can result in OSA, even in thin, fit people-  we look for large tongue, large tonsils, adenoids, high arched palate, receding lower jaw, known as retrognathia.

Poor muscle tone can lead to OSA as well. People who drink alcohol have their muscle tones relaxed resulting in a higher chance of snoring and sleep apnea. Patients taking narcotics or muscle relaxants like flexeril, or soma also can worsen their risk for OSA. I know of at least one research study published out of Brazil where they showed that neck muscle toning exercises can help improve mild to moderate OSA.

Every time there is an obstruction of the throat due to OSA, the brain gets panic signals and it goes into "microarousal"- so the sleep is very fragmented in patients with OSA- so they feel really tired and often sleepy in daytime. Every time there is choking and obstruction of throat, the adrenal galnds pump stress hormones resulting in heart rate and blood pressure going up and down all night long. The oxygen levels keeps dropping down with apnea. So, night time, which is supposed to be restful and rejuvenating for our system, becomes more like a battlefield. This puts a lot of strain on the blood vessels, the heart, and of course, the brain. There is also more inflammation in the body. The insulin does not work too well in patients with OSA. Due to all these bad changes in body overnight in patients with OSA, there is a higher risk of heart attack, atrial fibrillation, hypertension, congestive heart failure and strokes. Men, especially, have a 3-4 fold higher risk of stroke if they have OSA. Due to fragmented sleep in patients with OSA, they are tired, with reduced attention span, and they have a slightly higher risk of accidents as well. This is why the Federal DOT requires that truck dirvers, rail engineers, pilots, etc have medical check up to screen for and if needed full evaluation for OSA.

A good night's sleep for at least 8 hours is vital for good health.

Patient Flow

The smooth flow of patients through our offices is key to ensuring timely, effective, efficient, and high value care for our patients. What bottlenecks have you observed that slows down the flow? I will appreciate your feedback on this. What problems do you notice repeatedly, and what solution do you propose?
Thanks
Setu

Commonly prescribed COPD medications at our office

As you know, we have a large number of patients with COPD.  COPD is inflammatory in nature and marked by narrowing of the bronchial tubes. For patients with stable COPD, the medications will depend on the severity of COPD. A good summary report about COPD can be is available at GOLD guidelines.

For Mild COPD we generally use albuterol as needed.

For moderate COPD: we use Spiriva, and offer pulmonary rehab.

For severe COPD: we use Advair or Symbicort, or Dulera along with Spiriva; or we can use nebulized Pulmiocort+Perforomist or Pulmicort+Brovana

For patients who have an acute exacerbation of COPD- marked by increasing cough, sputum, wheezing, and shortness of breath- we treat with oral short course of prednisone and antibiotic such as azithromycin, or doxycycline, or levaquin if we suspect bacterial infection.

Patients who have severe COPD, and have had acute exacerbations with chronic bronchitis, a new medication called DALIRESP (ROFLUMILAST) is recently approved by the FDA. It is a preventive medicdation that reduces the risk of acute exacerbation of COPD. It is once a day pill. It cannot be given to patients with significant liver disease or to patients who have significant weight loss. It works as a phosphodiesterase-4 (PDE-4) inhibitor. It leads to increased cyclic AMP that lead to reduced inflammation and muscle relaxation.

We generally use nebulized albuterol, or Pulmicort, Perforomist, Brovana only in patients with severe COPD or those who have limitations in hand-breathing coordination, cognitive issues, arthritis, etc. where they are less likely to inhale the Advair or Symbicort easily.

Confirming that the patients are taking their COPD medications regularly at each office visit is very useful. It is also a good idea to check their inhaler technique. Using spacer for meter dose inhalers is a good idea.

The Value of Medical Receptionists

A study in the journal Social Science and Medicine highlights the critical role medical receptionists play in frontline patient care, noting that their responsibilities encompass much more than administrative duties.

Hospital ward clerks, unit secretaries, and office receptionists often are the first people patients see in clinics and hospitals. For the study, a researcher from the York Management School of the University of York in England observed and interviewed about 30 receptionists in general practice offices across three years.

The results showed that in addition to administrative duties, some receptionists dealt with up to 70 people in a single day. According to the findings, the work was often "emotionally challenging," as receptionists often had to perform other tasks including confirming prescriptions, helping mentally ill patients, congratulating new mothers, and consoling family members.

The study found that successful receptionists were able to adapt their emotions to meet patients' needs. However, emotionally distancing themselves from patients backfired at times, when patients perceived the receptionist to be "barring access to primary care," according to the author.

The author suggests that receptionists undergo training for how to deal with the emotional aspects of their role. Increased recognition and support also could lead to fewer misunderstandings with patients. For example, clinics could have explicit policies that require requests to see a physician to be fulfilled within 72 hours instead of 24 hours ( From the Advisory Board)
Also see the NY Times report.
Thank you for what you do so well.

Healthcare delivery as seen by the patient/family

This past Friday, grandpa V had a cardiac arrest. He was a very vibrant 89-year-old with many medical conditions. He was resuscitated, intubated and transferred to the hospital emergency department. We drove down friday night to be at his bedside in a Delaware ICU. We take care of such patients all the time. This was one more chance for me to be on the other side and see how the healthcare system works or does not work. I saw from a family's perspective what drives outcomes and patient/family experience. I hope the wonderful treatment we got was not because I was a physician. There were many things that worked well.

Communication: The emergency department physician and the attending cardiologist both got on the phone to update me as I was driving down I-95. They were open to ideas, and they started hypothermia protocol at my suggestion. The interventional cardiologist also called me before the procedure to explain the rationale and the risks.
Access: The nurse and the ICU allowed family visiting, and gave frequent updates. Doctors and nurses were available a phone call away.
Caring: The hospital sent a comfort cart with coffee, juices, muffins while we were at the bedside vigil. small touch, goes a long way. It showed that they cared.

So, inspite of a bad outcome--death, the family was pleased with the care provided at the ICU in Delaware and will always be grateful to the wonderful nurses, physicians, and the hospital staff for taking such good care of grandpa and us.

I relearnt my lessons.

What is a patient centered practice?

Patients are why we all are here. That is obvious. However, in the last few years, the concept of patient-centered medical homes have emerged. These are primary care practices that meet certain criteria listed below:
PCMH 1: Enhance Access and Continuity
PCMH 2: Identify and Manage Patient Populations
PCMH 3: Plan and Manage Care
PCMH 4: Provide Self-Care and Community Support
PCMH 5: Track and Coordinate Care
PCMH 6: Measure and Improve Performance

Although this is geared towards primary care, our office does have some primary care component and the model also makes sense for specialty care.
PCMH content and scoring details are found at NCQA website.
We can start by establishing registries of our patients with asthma, COPD, sarcoidosis, lung nodules, OSA.
We can also identify high-risk patients- based on their disease severity and psycho-soical factors.
Finally, getting a superb office EMR will let us become more patient-centered and do continuous quality improvement.

Understanding Lung Shadows

All of us come across chest xray or a CT scan report on our patients that mention infiltrates or nodules. Other times they mention a mass, or ground glass opacity. Let us try to understand the basics of these radiographic descriptions.

Infiltrate: generally describes a haziness in the part of lung that is denser than normal lung- it could often be seen in pneumonia. There are other conditions that can cause infiltrates- such as atelectasis (compressed lung segment).

Nodule: a density or opacity that measures less than 3 cm is called a nodule. It can be single or mulitple; it could be subcentimeter or more in size. Nodules are scary because we always worry about them being from cancer. We never want to miss a nodule patient in follow up. Many nodules turn out to be benign, from scar, or granuloma ( old infection). We need to closely monitor the nodule to make sure it is not growing in size. Depending on the size or the risk factor of individual patient, we may decide to either closely follow it by serial CT scan, or send patient for biopsy, or send the patient for thoracic surgery to take the nodule out surgically. Missed lung cancer in a patient with nodule is a high risk to our practice.

Mass: is generally a dense, 3 cm or more density, and it generally is concerning for cancer. Rarely pneumonia, or rounded atelectasis can mimic a mass. A mass usually needs urgent consultation followed by biopsy.

Have you come across other radiographic term that has puzzled you?

What is an ACO- Accountable Care Organization?

In the near future, office practices such as ours will have to join clinical forces with other practices- primary and specialty practices, and with the hospital. The government's idea is to ask such team to take on more responsibility for the wellbeing of the patients by coordinating clinical efforts and resources. The purpose of an ACO is to improve the quality of care while also reducing waste. This teamwork model requires collection and sharing of patient information. It also calls for measuring and reporting of quality and cost data. That is why an EMR is absolutely vital for the success of new model of care based on an ACO concept.
Each practice will be measured for its quality and value. The five broad areas where we will be evaluated are:
1. patient/caregiver care experiences
2. care coordination
3. patient safety
4. preventive health
5. at-risk population/frail elderly health

Let us look at patient/caregiver experiences measures.
We will have to survey our patients and report the following seven measures:

1. getting timely care, appointments, and information
2. how well your doctors communicate
3. helpful, courteous, respectful office staff
4. patient’s rating of doctor
5. health promotion and education
6. shared decision making
7. health status/functional status

You can see that there are areas where your input and leadership will be absolutely critical in making our office practice even more patient-centered. Any thoughts on this ?

Electronic Medical Records Goals

• Improve the quality and value of patient care
• Reduce administrative, staffing burden
• Immediate access to patient information
• Reduced medication errors
• Increase patient satisfaction through quicker patient intake, chart creation and throughputs
• Increased practice efficiency leading to a better use of your time

These are some of the benefits of having an office electronic medical record system. It is a necessity now. The selection process of an office EMR is a complex process where we have to look at many factors- how easy is it to use, how expensive, how does it communicate with the hospital, how does it communicate with other practices, etc.

The office staff at a medical practice are going to be using the EMR and will need to redesign the workflow to make patient care better, safer; make it easier for the physicians and also for the staff members themselves.

There are natural questions about how office EMR will affect staffing?

I suggest you read this link:

http://www.ama-assn.org/amednews/2009/10/05/bisa1005.htm

I am envisioning that EMR will redefine the roles of staff members, with more emphasis on patient education, manageing disease registry, etc.

I am excited about it.

What is Acute Exacerbation of COPD?

Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is an episode where the patient with COPD has more than usual cough, sputum, wheezing, and shortness of breath.

AECOPD is triggered by infection, pollution, smoking, and poor use of preventive medications.

AECOPD leads to emergency department visit or hospitalization. It is very expensive. One hospitalization costs the system about $7000. AECOPD is very bad for the patients as it leads to poor capacity to breath and to do any activities. It can often be fatal if it causes respiratory failure.

Our goal is to prevent AECOPD.
1. Educate patients to use their Advair or Symbicort, or Spiriva regularly.
2. Give patients the AECOPD Action Plan and prescription refill on standby to self-manage and inform us.
3. Encourage all patients to get vaccinations.
4. Encourage patients to join pulmonary rehab program if they have moderate or severe COPD.
5. Give a hospital follow up appointment ASAP to our patients hospitalized with AECOPD

What is Quality healthcare ?

Everyone is talking about quality these days.
From Toyota to TJC- The Joint Commission, the meaning of quality is an elusive, ever moving target.
Quality and reputation takes a lot of time and effort to build, but it can often be damaged in a short time-
Be it Toyota, or Tiger Woods.

"Doing the right thing, at the right time, for the right person, and having the best possible result"
is a definition of quality healthcare used by the federal Agency for Healthcare Research & Quality (AHRQ).

According to the Institute of Medicine (IOM), quality healthcare has six elements.
I suggest a mnemonic: Quality healthcare is a STEEEP mountain to climb.

Safe—first do no harm
Timely—reduce harmful delays for both those who receive and those who give care
Effective—provide care based on current scientific knowledge and avoid underuse and overuse
Efficient—avoid waste
Equitable—provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
Patient-centered— provide care that is guided by patient's values and needs

How do we measure quality ? Who is responsible for quality ?
These are the big questions to be explored next.

Welcome to MMQB

All of us in the healthcare profession know that the patient is at the center of all that we do. Our mission is to promote health, prevent disease, treat the whole patient, and when cure is not possible, to always provide comfort.
In part due to the rising and out of control healthcare cost, our national debt is more than 14 trillion dollars. The practice of medicine as we know it is changing right now. There is a rise of quality and patient safety movement that is changing the expectations and the payment system slowly.
The major change is Payment for Value. Value is equal to quality divided by the cost.
For private medical offices, the physicians and the staff will have to learn more about patient safety, high quality and low cost delivery of healthcare. The MMQB is specifically designed for the staff members of a medical office. If you are a medical assistant, receptionist, roomer, check-out staff, medical records keeper, biller, coder, office manager, or working in any other capacity, you are a vital part of the team that it takes to care for the patient and their loved ones.
Patient's life and all of our livelihoods depends on it.
Please join the conversation.