Health for life

Years ago, the Disease Management Care Blog crossed swords with a clinic administrator who was unsatisfied with its Departments patient satisfaction metrics. The DMCB argued sometimes having to say "no" to patients demands for easy cures, specialist errals, sophisticated imaging studies or off-formulary drugs could result in low satisfaction rates. It was about then that the DMCB was informed that the patient satisfaction surveys were going to be tied to portion of its income.

Administrator: 1, DMCB: 0.

Thats why years later, the DMCB feels partially redeemed by an interesting peer-reviewed publication that examines the lack of any relationship between patient satisfaction and patient centered care.  In case you think theyre both the same, think again.

Writing in the July 11 issue of JAMA, authors Joel Kupfer and Edward Bond point out that the former is a consumerist concept that compares service or product delivery to customers expectations, while the latter is a medical concept that uses patient values to guide medical decision making.

Its been long-known that exceeding expectations leads to customer loyalty which, in turn, leads to greater profits. Thats one of the reasons why business-minded hospital administrators typically rely on satisfaction surveys as a key metric of success. Despite their wide use in health care settings, however, Drs. Kupfer and Bond find that "satisfaction" is a poorly researched concept that has little correlation with the important domains of quality, safety, effectiveness, efficiency or equitability. For example, its possible for over-testing and over-prescribing to give patients the false impression of action and progress. In addition, because patients dont usually bear the full cost of medical care, their opinions dont have to reconcile price and product, like they would for a car or a bottle of shampoo.

What did the DMCB learn, other than, once again, it was right all along?

1. Building a patient centered medical care practice wont necessarily generate high patient satisfaction. Conversely, pursuing high satisfaction rates is not the same as initiating patient centered medical care.

2. "Patient satisfaction rates" are a Ver. 1.0 primitive window into one slice of patient experience that, by itself, ultimately offers little insight about overall quality.  Patients and their doctors deserve better.

What do urine color and odor changes mean? How often should you go

Urine isnt something most people talk about. We barely give it more than a passing glance as it swirls out of sight down the toilet bowl. Yet changes in the urine – its color, odor, and consistency – can provide important clues about the status of your body. Your urine can reveal what youve been eating, how much youve been drinking, and what diseases you have.

"Urine and urinalysis have, for hundreds of years, been one of the ways physicians have looked at health," says Tomas Griebling, MD, MPH, vice chair of the urology department at the University of Kansas.
"From a historical view, urinalysis was one of the original windows into whats happening in the body," Griebling says. Thats because many of the substances circulating in your body, including bacteria, yeast, excess protein and sugar, eventually make their way into the urine.
Urine is an important part of the bodys disposal process. Its job is to remove the extra water and water-soluble wastes the kidneys filter out of the blood. "The urine is there primarily to get rid of toxins or things that would otherwise build up in the body that would be bad for the body," says Anthony Smith, MD, professor and chief of urology at the University of New Mexico.
When you notice that your urine has changed color, or theres a strange odor wafting up from the toilet, the cause might be something as harmless as what you had for dinner (which could have included beets or asparagus). It also might be a sign of a more serious condition, such as an infection or cancer.
Before you flush, here are a few urine changes to look out for, and what they might be saying about your health.

Color Changes
Urine gets its yellow color from a pigment called urochrome. That color normally varies from pale yellow to deep amber, depending on the concentration of the urine. Darker urine is usually a sign that youre not drinking enough fluid. "Your body needs a certain amount of fluid to function, so the body will hold on to fluid and the urine will become very strong and concentrated. When that happens, it will turn a darker color," Griebling says.
The opposite is also true. If your urine is very pale, it means that youre either drinking a lot of fluid, or youre taking a diuretic -- a drug that forces the body to get rid of excess water.
Urine can turn a rainbow of colors, and an unusual hue isnt necessarily cause for alarm. Certain medications can turn the urine fluorescent green or blue, carrots can tint it orange, vitamins can give it a yellow hue, and an inherited disease called porphyria can shade it the color of port wine.
Seeing red is typically a sign that there is blood in the urine, but before you panic, know that a little blood can produce a dramatic color change. "What I always tell patients is it takes one drop of blood to turn a toilet bowl red," Smith says.
That said, just a little blood in the urine can be a sign of something serious, like an infection or cancer, and it warrants a visit to your doctor or urologist. If youre seeing blood and your urine is also cloudy, theres a good chance youve picked up an infection, Smith says.

Odor Changes

Urine normally doesnt have a very strong smell. If you get a whiff of something particularly pungent, you could have an infection or urinary stones, which can create an ammonia-like odor. Diabetics might notice that their urine smells sweet, because of excess sugar. In the past, doctors would actually taste urine for this sweetness to diagnose diabetes.
Some foods can also change urine odor. Asparagus is among the most notorious. What people are smelling when they eat asparagus is the breakdown of a sulfur compound called methyl mercaptan (the same compound found in garlic and skunk secretions). If you catch a whiff of something after eating a plate of asparagus, it means that youve inherited the gene for the enzyme that breaks down mercaptan. Not everyone has this enzyme and, theore, not everyone can smell it.

How Often Do You Need to Go?

How often you need to go can be as important an indicator of your health as the color or smell of your urine. Most people take bathroom breaks about six to eight times a day, but you might go more or less depending on how much fluid you drink. If youre constantly feeling the urge to go and its not because youre not drinking extra fluid, causes can include:
• Overactive bladder -- involuntary contractions of the bladder muscle
• Urinary tract infection
• Interstitial cystitis -- a condition that causes the bladder wall to become inflamed and irritated
• Benign prostate enlargement -- growth of the prostate that causes it to squeeze the urethra and block the normal flow of urine out of the body
• Neurological diseases, including stroke and Parkinsons disease
• Diabetes
The opposite problem -- not going to the bathroom enough -- can occur when there is a blockage or infection. Or, it can be the result of bad bathroom habits. Some people -- especially teachers, surgeons, and anyone else who doesnt have time for regular bathroom breaks throughout the day -- tend to hold it in.
Delaying urination can be problematic, says Smith, who compares the bladder to a Slinky: It stretches and then contracts repeatedly, but eventually it can stretch too much to bounce back. "The bladder can develop a chronic overdistension…a chronic emptying problem," he says.

Developing Healthy Bathroom Habits

Take good care of your bladder, and it will thank you by helping you urinate regularly. To avoid having to make too many bathroom visits, stay hydrated, but not overhydrated. Drink whenever youre thirsty, but dont feel as though you have to adhere to the eight-glasses-a-day recommendation (unless you have kidney or bladder stones, in which case youll need to increase your fluid intake).
If youre getting up during the night to use the bathroom, stop drinking three to four hours before bedtime. Limit caffeine, which can irritate the lining of the bladder. Also watch your intake of alcohol, which can have similar effects.
Finally, dont hold it in. As soon as you feel the urge to go, excuse yourself from whatever youre doing and find a bathroom.

According to this just-released Health and Human Services Issue Brief, the percent of U.S. physicians "accepting new Medicare patients" increased from 87.9% in 2005 to 90.7% in 2012. Whats more, this rate of uptake of new Medicare beneficiaries is tracking higher than the rate of "new privately insured patients."

The Issue also says there "may" have been a "very small increase" in the number of docs who have dropped out of the Medicare program. Those drop-outs appear to be greatest among psychiatrists (1.1%) and plastic surgeons (1.6%). In contrast, only 0.35% of primary care physicians have dropped out. These drop-outs have been more than compensated for by the new physicians entering the labor market.

Except for 2012, these data are from the in person interviews that comprise the National Ambulatory Medical Care Survey, The 2012 numbers are described as "interim," because they are based on a mail-in survey.

The Issue brief also quotes a separate MedPAC annual survey of thousands of Medicare beneficiaries. According to the brief, 77% reported they never experienced a delay in getting an appointment for routine care, compared with 76% in 2008.

Case closed, right?  The Disease Management Care Blogs dire warnings about a widespread provider exit from Medicare that was echoed years later by the Wall Street Journal have been overblown.

Not exactly, speculates the DMCB, for the following reasons:

1. The DMCB pulled a copy of the NAMCS survey and found the question that was apparently used to assess physician participation. The screen shot is above. It generically ers to "Medicare," not fee-for-service Medicare.  Because many physicians are members of insurance networks, an affirmative answer could be misinterpreted by the respondents as erring to Medicare Advantage. 

2. There is a difference between "accepting" new patients vs. welcoming new patients. In this seminal New England Journal study, many respondents "accepted" "new" Medicaid beneficiaries, but moved them to the back of the appointment queue.

That being said, the MedPAC survey suggests that isnt happening           - yet - to Medicare beneficiaries. And thats assuming a health care consumers definition of "delay" hasnt been dumbed down since 2005.   

3. Last but not least, the NAMCS numbers represent a national average. Many areas of the country have seen consolidation of physician practices into larger groups. The DMCB suspects these entities are more willing to accommodate Medicare beneficiaries. Its very possible that the smaller physician-owned practices - many of whom practice in rural areas - are less likely to do so in 2013 than they were in 2008.

Coda:

In yesterdays post, the DMCB was introduced to "twerking." After additional inquiries of the DMCB spawn, it has learned more about this curious phenomenon. 

Which led to this insight:

Q: What is one key similarity between twerking and being an ACO?

A: You better be caul doing both, otherwise you could get screwed.



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