Monday, 08 February 2016 03:13

Response to “Mystery Patients” Article

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“Thanks to Dr. Hirsch for pointing out the errors in the introductory case study in my ‘Mystery Patients’ article. I regret them, and l apologize to VPBmonitor and its readers. I hope these inaccuracies don’t diminish for readers the impact and implications of the groundbreaking research described later in the article." 

- Phil Nathanson, president, Nathanson Consulting LLC

A recent article on VBPmonitor by Philip Nathanson highlighted the problem of contextual errors in medical decision-making and discussed the use of “mystery patients” to evaluate the ability of providers to extract important contextual information to better treat all patients. The discussion is fascinating, addressing an important topic, but he introduced it with a case example that contains several errors worth noting. His case involves a patient who was prescribed cholesterol-lowering medication (a statin) to take at bedtime and went on to have a fatal heart attack.

Mr. Nathanson faults the physician for simply telling the patient to take the medication at bedtime without realizing that the patient works a night shift, so for him, bedtime is actually morning. The recommendation to take a statin at night is not related to the time on the clock, but to a patient’s sleep pattern and when they are fasting for the longest period (usually during sleep). Therefore, the patient was correct to take the medication upon going to sleep, even though it was what most of us call the morning. The patient was also prescribed atorvastatin, a statin which has a long half-life, meaning that the timing is not important.

Second, the current recommendation from the American Heart Association is not to recheck lipid levels after a statin is prescribed; adherence should be assessed by questioning the patient, as was done. The effects of statins go beyond just their ability to lower cholesterol levels; in other words, their beneficial effects include reducing inflammation that leads to heart attacks.

Third, the author implies that properly administered statins prevent all heart attacks. That is far from the truth. Statins reduce the risk of a heart attack by approximately 20-30 percent. We do not know if the patient was diabetic, a smoker, had hypertension, had a family history, etc., all of which contribute to risk of heart attack independent of cholesterol level. As an example, if the patient’s baseline risk of having a heart attack in the next 10 years was 20 percent, a potent statin such as atorvastatin would lower that risk to about 15 percent. That means that for every 100 patients taking a statin properly, five would avoid having a heart attack, but 15 still would have a heart attack despite taking every dose of the medication exactly as prescribed. This patient was one of those 15. It was not a failure of the medication, a failure of the patient to follow directions (if he did indeed take the medication as he said he did), or, most importantly, a failure of the doctor to consider patient context. Even with the best of treatments, bad things happen. We don’t always need to blame the doctor when they do.

In Mr. Nathanson’s defense, I should point out that he describes an excellent case later in the article that properly addresses contextualizing care; this was a patient with heart failure who binged on salty foods. Many elderly patients are on fixed budgets and often have to decide between paying for their medications or choosing healthy foods when they go to the grocery store. As a result, they buy salt-laden, canned, and packaged food – and they end up exacerbating their heart failure.

Finally, allow me to point out that it is not always the providers that do not contextualize care. Mr. Nathanson also describes a patient who could not afford his asthma medication and had to “stretch it out.” Insurance companies often forget to contextualize when they limit prescriptions to a certain quantity. That same asthmatic may have used up his inhaler faster because of an exacerbation that required more frequent use, as instructed by his physician, but the insurance company then would refuse his refill request because “the refill is too early.” That lack of context by the insurance company may lead to a hospitalization for an asthma exacerbation, increasing costs and endangering the patient.

About the Author

Ronald Hirsch, M.D. serves as vice president of physician advisory services (AccretivePAS®) in the Regulation and Education Group (“the REG Specialists”). Prior to his employment at Accretive Health, Dr. Hirsch, a board-certified internist and HIV specialist, practiced and served as president of a multispecialty practice in Illinois and medical director of case management at Sherman Hospital in Elgin, Ill.

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Last modified on Tuesday, 09 February 2016 04:46

Ronald Hirsch, M.D. serves as vice president of physician advisory services (AccretivePAS®) in the Regulation and Education Group ("the REG Specialists"). Prior to his employment at Accretive Health, Dr. Hirsch, a board-certified internist and HIV specialist, practiced and served as president of a multispecialty practice in Illinois and medical director of case management at Sherman Hospital in Elgin, Ill.