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Mon, July 31, 2017

David Sandberg was recently quoted in BuzzFeed article, "A Landmark Lawsuit About An Intersex Baby’s Genital Surgery Just Settled For $440,000." Dr. Sandberg is the coinvestigator of a research initiative across several hospitals to try to better understand outcomes of patients with differences of sexual development.

Thu, September 28, 2017

Geoff Barnes was recently interviewed for the article, "Stroke, Bleeding Risks High in A-fib Patients With Contraindications to Anticoagulation" in tctMD/the heart beat.

Fri, November 17, 2017

Naomi Laventhal and Kayte Spector-Bagdady were quoted in Michigan Medicine for the article, "Born at the Right Time" about an artificial placenta being developed at C.S. Mott Children’s Hospital for the treatment of extreme prematurity.

Samantha Harrison, MPH

Research Associate

Sam joined CBSSM in November 2017. She works with Drs. Julie Wright, Michele Gornick, and Renuka Tipirneni on projects examining provider-patient communication regarding chronic kidney disease, VA data sharing, and the effect of Medicaid expansion on healthcare for low-SES aging adults.

Last Name: 
Harrison

CBSSM Faculty, Kayte Spector-Bagdady, Ray De Vries, and Lisa Harris, along with Lisa Low recently co-authored a Hastings Center Report article, "Stemming the Standard-of-Care Sprawl" about clinician self-interest and the case of electronic fetal monitoring.

Link to article here.

Research Topics: 

Joel Howell was honored by the American College of Physicians (ACP) at its annual convocation ceremony in April. Howell was named a new Master of the American College of Physicians for 2017-2018. Each year, a select group of these Fellows are chosen from among the nominees for Mastership by the ACP Awards Committee and approved by the ACP Board of Regents.

When Money is Tight (Jul-04)

Because of the high cost of many prescription drugs, some people take fewer pills than prescribed. What are the health implications?

Imagine that four months ago, you started getting chest pains whenever you exerted yourself physically, and at the time you decided this was serious enough to see a doctor. After your doctor examined you and ran some tests, you were told that you have angina, a kind of heart disease. This disease can develop when the coronary arteries become narrow and clogged from high cholesterol and the heart can't get the oxygen that it needs. Your doctor helped you plan some lifestyle changes to treat your condition. You have been very devoted to the new way of life, eating healthier and doing the proper kinds of exercise regularly. Also, part of your treatment involves regularly taking the medication that your doctor prescribed for you. You were told to take one pill each day.

The trouble is your prescription drug insurance is limited and you find yourself having to pay the majority of the cost for the angina medication out of pocket. What's more, you have been struggling just to break even every month after accounting for all of your living expenses. Now you are worried about being able to afford the medication if you take it as regularly as prescribed. A pill a day may be doctor's orders, but it is getting costly for you.
 
Would you take the pill as often as prescribed or would you skip some days to try to save money?
 
  • I would take the pill every day as prescribed.
  • I would skip some days to save some money.

How do your answers compare?

You have to save money somehow, right? Perhaps you would just have to cut back on other expenses in your life, but apparently you felt the medication had to be taken as prescribed. Research has found, however, that especially among the elderly, a significant portion of the population reports restricting medications due to cost. An important question is whether this leads to adverse health outcomes. Policy debates have been largely divided on this issue.

Do those who restrict their medications due to cost experience adverse health outcomes?

A research team led by Dr. Michele Heisler and Dr. Kenneth Langa conducted a study to investigate this question. Prior to this study, no one had examined this question by studying the same individuals at different points in time to see if those who restricted medication due to cost were more likely to develop adverse health outcomes. The researchers obtained nationally representative data that was the result of nearly 8000 interviews. Each respondent was interviewed in 1995 or 1996 and then re-interviewed in 1998. At both times, individuals were asked about cost-related medication restriction and about their health. The health questions assessed overall health, angina and other cardiovascular diseases, diabetes, arthritis, and depression.

The researchers found that cost-related medication restriction was associated with almost twice the odds of experiencing a significant decline in overall health. The association between restricting medication due to cost and poor health outcomes was strongest for those who had cardiovascular disease. Of these individuals, those who restricted their medication had a 50% increased odds of suffering angina and a 51% increased odds of having a stroke. Aren't you glad on the previous page you said you wouldn't restrict your angina medication?

Those who had arthritis or diabetes and restricted their medication due to cost did not report worse disease-related outcomes at the second interview. For arthritis, this might have been because of equally effective over-the-counter pain medications, and for diabetes, higher rates of kidney disease would likely require a longer period of follow-up to detect. When looking at age as a factor, the results showed that older adults experienced significant declines in overall health, worse cardiovascular outcomes, and increased depression. The study showed that younger people who restrict are also at risk for a decline in their health.

One limitation of this study is the lack of data about how often individuals restricted medications. If an individual restricted only once or twice, it is not clinically plausible that this would have led to an adverse health outcome. Also, the data on health outcomes were self-reported, and thus subject to bias. Previous studies, however, have shown excellent agreement between medical records and self-reports for conditions such as hypertension, diabetes, and stroke.

Implications on policy

This study provides evidence that, contrary to some claims, adults with chronic illnesses who restrict medications due to cost experience adverse health outcomes. As drug costs continue to escalate and individuals continue to lack full prescription coverage from their health insurance, it will be increasingly important for healthcare systems and physicians to develop strategies to screen patients for cost-related underuse of medications and to provide assistance to these patients. Moreover, insurance companies will need to create benefit packages that provide appropriate coverage, taking into account the cost of prescription medications.

For more information see:

Michele Heisler, Kenneth M. Langa, Elizabeth L. Eby, A. Mark Fendrick, Mohammed U. Kabeto, John D. Piette. The Health Effects of Restricting Prescription Medication Use Because of Cost. Medical Care, 42(7). 2004.

Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

Bioethics Grand Rounds

Wed, June 27, 2018, 12:00pm
Location: 
UH Ford Auditorium

Title: Use of Preventive Ethics Rounds to Identify, Anticipate, and Proactively Address Ethical Dilemmas

Presenters: Janice Firn, PhD, LMSW,  Katie Feder, M2, Sally Salari, M4

The intersection of complex, critical illness and evolving medical technology in hospital intensive care units (ICUs) drives ethical dilemmas which in turn affect patient care and contribute to moral distress and burnout in providers. Rounding regularly in ICUs allows clinical ethicists to proactively intervene in ethically challenging cases at a time when they are most amenable to intervention. Through case discussion, clinical ethicists can help educate and support critical care providers in thinking through ethical issues pertinent to patient care throughout the hospital course. This approach can be helpful in offering a common language and framework for addressing ethical issues in every day clinical practice. To provide real-time education in the clinical context and early identification of ethical issues, Michigan Medicine initiated novel, system-wide “preventive ethics rounds” in all the ICUs (medical and surgical, adult and pediatric) in the form of a pre-consult rounding service. Providers use ethics related tools to constructively work through difficult cases as they arise; which can improve patient care and ameliorate moral distress. The presenters will address the ways in which preventative ethics rounds have impacted the formal consultation process, the types of ethical issues and patient characteristics discussed during rounds, and if/how these differ from those discussed during formal ethics consultation.

Bioethics Grand Rounds -Benjamen Berkman, JD, MPH

Wed, November 28, 2018, 12:00pm
Location: 
University Hospital Ford Auditorium

“Reexamining the Right Not to Know Genetic Information”

While promising to eventually revolutionize medical research and practice, the capacity to cheaply and quickly generate an individual's entire genome has not been without controversy. Producing information on this scale seems to violate some of the accepted norms governing how to practice medicine, norms that evolved during the early years of genetic testing when a targeted paradigm dominated. One of these widely accepted norms was that an individual has a right not to know genetic information about him or herself. Prompted by evolving professional practice guidelines, the right not to know has become a highly controversial topic, particularly in the context of research utilizing genomic sequencing. The medical community and bioethicists are actively engaged in a contentious debate about the extent to which individual choice should play a role (if at all) in determining which clinically significant findings are returned. This talk will explore the extent to which it is legally and ethically necessary to respect the so-called right not to know genetic information about oneself. Challenging the majority view that the right not to know is sacrosanct, the speaker will push back against that vigorously held (although not always rigorously defended) position, in defense of the idea that we should abandon the notion of a strong right not to know. Drawing on the fields of law, philosophy and social science, he will provide an extended argument in support of a default for returning high value genetic information without asking about a preference not to know. He will conclude by providing some recommendations about how best to balance individual autonomy and professional beneficence as the field of genomic medicine continues to evolve.

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