On strep throats, tonsillitis, and tonsillectomies

January 10, 2011  |  General  |  1 Comment

There are some important new recommendations about tonsillectomy — taking out the tonsils — as a treatment for recurrent strep throats. You can read about it here.

Some of us can recall a time when getting your tonsils out was one of the rites of passage of childhood. Usually a related procedure is added — an adenoidectomy, removing the adenoids as well. It’s called a T&A in the medical world, and it’s one of the most common surgical procedures done on children.

Where are the tonsils, what do they do, and why would we take them out? The tonsils are at the back of the throat, one on either side. If they haven’t been removed, you can see them peeking at you when you open your mouth wide and look in the mirror. Both are part of your immune system, similar to lymph nodes (the “glands” you can feel at the front of your neck). As part of the immune system, the tonsils fight infection; they are first line of defense in the throat, and when they are doing their job fighting infections, you get a sore throat. The tonsils usually swell a bit and get red when that’s happening. Here’s a picture of them:

The connection between tonsils doing their job and strep throats is that a common cause of tonsillitis in children is a strep infection. Before we had antibiotics, removing the tonsils was one way to combat recurrent strep infections. As soon as penicillin, one of the first antibiotics, came along, though, we instantly had an effective nonsurgical treatment for strep tonsillitis. Nearly all of the time it works, primarily because the strep bacteria has maintained its sensitivity to penicillin — we haven’t seen the antibiotic resistance that bedevils our ability to treat other bacterial infections.

But children do get a lot of strep infections, and some children have recurrent strep, sometimes multiple times each winter. For those children, doctors often recommended taking the tonsils out. Before I went into critical care, I first trained and practiced as a pediatric infectious disease specialist, and I was consulted many times about such children. My bias was nearly always against tonsillectomy. My reason, shared by most infectious disease experts, was that we have effective antibiotics to treat strep. Why risk the surgery?

A key point is that recurrent strep tonsillitis nearly always gets better with age no matter what we do. This makes tonsillectomy look good, because the natural history of the illness is to improve. I’ve met dozens of parents who say their child (or themselves as children) had constant strep infections until the tonsils came out. Often these same parents (and especially their grandparents) had had their tonsils out as children and more or less regarded tonsillectomy as something children need, like vaccinations. But frequent courses of penicillin, one of the safest medications on the planet (if your child is not allergic to it, of course), nearly always ultimately lead to the same favorable result as the tonsillectomy. (If your child is allergic to penicillin, we have other safe options.)

The important thing to remember is that tonsillectomy, like any surgery, is not without risk. It’s not just a routine thing like getting a vaccine shot. Compared with other surgical procedures the risk is low, but it is not zero. There are risks of bleeding afterward, sometimes life-threatening, and there are other risks associated with the anesthesia needed. Every year I see at least one child in the PICU who has suffered a complication from a tonsillectomy.

There still is a place for tonsillectomy for some cases of strep. Abscesses around the tonsils are one example. Tonsillectomy can also be very helpful for persons whose tonsils are so large that they block the airway, especially when they sleep (a condition called sleep apnea). But for the bulk of children with recurrent strep throats, it’s generally best to wait it out, treating each infection with antibiotics.

With everything we do in medicine, it’s important to weigh the benefit of the treatment against its risks: for recurrent strep tonsillitis, most of the time the calculus favors antibiotics. The importance of these new guidelines is that such a viewpoint is now the standard one.

Government payment for health care: the long view perspective

January 5, 2011  |  General  |  No Comments

With all the arguing about how to pay for healthcare it’s useful to step back and take a long, comparative view. To do that takes both knowledge and experience. Victor Fuchs, distinguished professor of economics and healthcare policy at Stanford, has both of those qualities, and recently shared his perspective in an excellent editorial in the New England Journal of Medicine here. A simple graph serves as his reference point.

What the graph shows is that, since 1960, governmental payment for healthcare has been steadily increasing as private payment has been decreasing; in 1960 the split was 80% private, 20% government. The two are nearly at parity now, a 50/50 split.

Fuch’s points out that, although the government pays for half the care, it makes relatively little attempt to use that clout to restrain costs:

Thus, in one sense, Americans wind up in the worst of all worlds, with government bearing a big part of the burden of paying for health care, with the concomitant large burden of taxes, but exercising very little control over the cost of care. As an indication of how absurd the situation is in the United States, government currently spends more per capita for health care than eight European countries spend from all sources on health care.

One of my principal concerns with how we do things now is that I think insurance companies add a large measure of cost without adding much value. We simply cannot continue to devote the huge chunk of our GDP that goes to healthcare, a number that is steadily rising.

The solution will be a political one, as it should be. But people should look at Fuch’s simple graph and realize that government already is the largest single payer. Judging from the firestorm of rhetoric in the last election about keeping Medicare strong, I don’t see that changing.

Whooping cough (pertussis) and civil rights

December 30, 2010  |  General  |  No Comments

I’ve written before about whooping cough, or pertussis, and its vaccine. It’s a potentially deadly illness for infants. There’s been quite a large epidemic of whooping cough over the past few months in California. In fact, it’s shaping up to be the largest epidemic in fifty years. Five infants have died as a result.

We have a vaccine for it, although it’s not an ideal one. For one thing, it can’t be given to the youngest of infants, those at most risk of dying from the disease. For another, the protection the vaccine gives wanes with age, requiring booster shots. The upshot is that those receiving the vaccine are getting it as much (or more) to protect others than to protect themselves. That raises the key question of to what extent it is our civic duty to get the vaccine, and give it to our children, to protect those very small, vulnerable infants who can’t get it yet. Freedom of choice collides with the public welfare.

Dr. Bill Schaffner, a distinguished infectious disease expert at Vanderbilt University, recently weighed on on the question of compulsory vaccination in this context. He writes:

“But here’s a reason [for refusing vaccine] that really makes me cringe — our society puts more value on personal choice than on protecting our fellow citizens. “Mandates” has become a dirty word. We don’t like mandating anything in this country. No, we’re not going to mandate and take away personal choice. But what choice did those five infants have? Does our thirst for individual freedom absolve us of our responsibility to protect them?”

There is precedent from the past for compelling people to do things for public health reasons. Old quarantine laws are one example. Of course making a sick person stay at home does not force them to get a particular treatment, such as a vaccination. There is a parallel, however, with tuberculosis treatment. There have been instances when courts have confined a person with active TB and forced them to receive treatment for it. Although this treated the person, the reason for the compulsory treatment was that it protected the community.

As a trained infectious disease specialist myself, I have do doubt that the vaccine, although not ideal, works. You will find people who disagree with that statement. What interests me the most on the issue is the question of civil rights: to what extent does the state have the right to compel its citizens to do something to protect the health of others? The answer, I think, is — it depends.

US health care stacks up poorly with other countries. Again.

December 24, 2010  |  General  |  1 Comment

A recent study by the Commonwealth Fund highlights what Americans experience in what passes for our healthcare “system” — higher costs, higher risks, and more stress. You can read about it on Chris Fleming’s excellent Health Affairs blog here, or else see the full study published here, in the journal Health Affairs.

The study surveyed eleven countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Survey samples sizes per country ranged from 1,000 to more than 3,500. From Chris Fleming’s blog, here’s a taste of a few things the survey showed.

• Twenty percent of US adults surveyed said they had had serious problems paying medical bills in the previous year. Responses to the same question from the other ten countries were all in the single digits. US respondents were also significantly more likely than adults in other countries to have gone without care because of cost.

• Thirty-five percent of US adults had out-of-pocket medical spending of $1,000 during the previous year, a far higher percentage than in any other country.

• Nearly one third of US adults (31 percent) reported either denial of payments by insurers or time-consuming interactions with insurers, a higher rate than in all other countries. Twenty-five percent of US respondents reported that their insurance company denied payment or did not pay as much as expected; 17 percent said they spent a lot of time on paperwork or disputes for medical bills or insurance — the highest rates in the survey.

• The United States had the widest and most pervasive differences in access and affordability by income of the eleven countries. The United Kingdom had the least.

We didn’t finish last in everything, at least — patients in Canada, Norway, and Sweden reported longer waits on average to see the doctor. But the key point to me is that America spends far, far more per capita on healthcare than any other country. For what we’re paying, we should get the best. We’re not. And those costs just have to come down — they’re unsustainable.

Statistics about children’s use of emergency departments

December 17, 2010  |  General  |  No Comments

It’s pretty well known that emergency room use is on the increase. This recent study summarized the trend over the past decade (the complete article is behind a paywall — let me know if anybody wants a complete copy). The authors compared 1997 with 2007, looking at the number of ED visits per 1000 population. They found that the total number of visits had increased from 353 per 1000 persons in 1997 to 390 per 1000 persons. The total number of visits was about double what you would predict just from population growth. So more folks have been going to the ED over the past decade. How many of these were children?

It turns out that the rate among children has not changed significantly over the past decade — it’s stable at 362 per 1000 population. So the past decade’s growth in ED use has come from other age groups. The study found all adults between 18 and 64 years of age increased their rate of use. Interestingly, older people, those over 65, did not.

ED use by insurance status confirmed what all of us have known for quite some time: the uninsured and those with Medicaid have the highest rate of ED use. A patient with Medicaid was roughly twice likely as a patient with insurance to go to the ED for care, and someone with no insurance was half again as likely to go to the ED as an insured person. The reason for this is most likely little or no access to regular primary care, care which would keep them out of the ED. It’s getting harder and harder for kids on Medicaid to find a doctor, largely because the reimbursement rate is so bad. In my state, for example, a pediatrician gets paid less to see a child with complicated health problems than it costs to change the oil in your car.

Another recent study, this one just involving children, examines the issue of inappropriate ED use. After all, if children can get care from a regular doctor, they are less likely to use the ED to get routine care. (Unfortunately there’s a paywall on this article, too.)

The authors examined the characteristics of what they called “inappropriate” use of the ED — essentially things for which, if the child had a regular doctor, they would not have come to the ED. Their findings also confirmed what we would have suspected: poor kids, kids on Medicaid, and uninsured kids — those who had trouble finding a regular doctor — were more likely to use the ED for routine care. ED care is extremely expensive care: the same visit for asthma, for example, is far cheaper in the office than in the ED. But if you’re a parent whose child is without regular healthcare, where are you supposed to go, if not the ED? From the article:

“Specifically, patients identified access barriers in the primary care clinic as the major reason for choosing the ED instead of the clinic. They reported a cumbersome scheduling system, long waiting times for appointments, and no availability of walk-in care.”

All this seems obvious. But sometimes we need actual research studies to confirm the intuitively obvious. And excessive ED use is one of the engines in our ever-increasing healthcare bills.

Are hospitals getting safer?

December 9, 2010  |  General  |  No Comments

Ten years ago a report by the Institute of Medicine, a branch of the National Academy of Sciences, more or less launched the patient safety movement with its estimate that medical error was responsible for something like 50-100,000 deaths annually. That’s a chilling statistic. It’s also one that has been disputed as overblown. But overblown or not, since then all hospitals have made intensive efforts to make them safer places for patients, using things like checklists, time-outs before procedures, and many other simple but crucial things to make sure we are doing the right thing to the right patient. So how are we doing? Are hospitals any safer than they were a decade ago?

Dr. Bob Wachter, one of the gurus of the patient safety movement, recently assessed where we are. His answer is no worse at least, probably a bit better, but not dramatically better. You can read his very informed opinion about it here, on the Health Care Blog. He thinks that, overall, we’ve turned the corner on patient safety and are at last moving in the right direction.

A lot of this research is with adult patients, not children. My own opinion is that the PICU is, in fact, a safer place than it was a decade ago. We are using checklists for common PICU procedures, such as placement of central venous catheters. We are methodical and stringent about looking for signs of skin sores in bedridden PICU patients. Our physician order entry is now all computerized, and the computer regularly picks up problematic orders, things like potentially unsafe drug interactions duplicate orders.

So I’m with Bob; I think hospitals are safer places than they were 10 years ago. We still have a long way to go. The most important thing the patient safety movement has taught us is to take a systems approach to error prevention. Because, as the Institute of Medicine titled their landmark study: “To err is human.”

Observing medical students: how will they learn if we don’t watch them with patients?

December 5, 2010  |  General  |  No Comments

I went off to medical school thirty-seven years ago. For the era, I went to what folks regarded as a very progressive place. It had a curriculum that was quite revolutionary for the time. Among other things, we started having interactions with actual patients during our first year, rather than the third year, as was traditional then. These days many, probably most, medical schools get their students seeing real patients sooner. That’s good. But do these students get any sort of planned, structured assessments with how they’re doing with those real patients? Does anybody watch them, encourage what they’re doing right and correct what they’re doing wrong?

A recent editorial in the journal Pediatrics, the official journal of the American Academy of Pediatrics, has an enlightening title: “Oh, what you can see: the role of observation in medical student education.” It turns out that students often don’t get what they need to learn how to do things right. (The full article at the link is behind a pay wall — if anybody wants the full editorial, let me know.)

It turns out that during their pediatric rotation only 57% of students have a faculty member observe them throughout the entire process of meeting a child and family, taking a medical history, and doing a physical examination. In my day I think it was worse than that: I can’t even recall having a teacher watch me go through the entire process; generally, the students would watch the teacher, then go off and try things on their own. Of course we weren’t allowed to do anything involving needles and such without training and supervision (at least at first), but thinking back it is surprising that we were mostly left to ourselves.

The rationale for direct observation is straightforward and obvious. In the words of the authors:

“The aim of direct clinical observation is clear — to help preceptors gather accurate information about students’ actual performance in real-life clinical settings rather than inferring performance. Preceptors can then provide effective, timely, and specific feedback on observed skills that can be incorporated into subsequent clinical encounters. With better supervision of learners, both student skills and clinical care improve.”

It seems obvious. Our colleagues in internal medicine are doing even worse they we are in pediatrics, though: the survey found that only 22% of students had an in-depth patient encounter observed by one of their teachers. Teachers of surgery, too, evaluated students “primarily on the basis of their own interactions with students rather than on observed clinical interactions with patients.”

The authors’ conclusion is self-evident, but at times somebody needs to point out the obvious:

“Focused, direct observation of medical students in clinical settings provides valuable information about learners’ skills in history-taking, communication, physical examination, and providing information to children and parents. Observing students’ encounters with patients improves teaching, evaluation, preceptor satisfaction, student satisfaction, and, ultimately, patient care. For the great clinical teacher, direct observation is worth the effort.”

Removing infant cold medicines from the market has reduced untoward events from them

December 1, 2010  |  General  |  No Comments

No pediatrician I know has ever liked any of the many over-the-counter cough and cold remedies very much, especially for very young children. There never has been any evidence that they help cold symptoms, and what’s in them (typically a decongestant and an antihistamine) can cause actual harm to children. Risking harm for dubious benefit is never a good trade-off in medical practice. I’ve seen more than a few kids over the years need to be admitted to the PICU because they have overdosed on these medications, either because they got into the meds and took them themselves or because their parents miscalculated the dose and gave too much.

Recognizing the problem, the makers of these products agreed voluntarily three years ago to take the ones intended for children less than two years of age off the market. These were usually various kinds of drops. Did this new policy have any effect? A recent study in the journal Pediatrics, the official journal of the American Academy of Pediatrics, suggests that it did.

The authors looked at emergency room visits before and after the product withdrawal went into effect. They sampled sixty-three representative pediatric emergency rooms across the country. What they found is that the number of trips to the ER for untoward effects from these medications — overdoses or just funny reactions — dropped by half. Such ER visits for children older than two did not change. Of course, as we say, correlation doesn’t prove causation, so it may have been a coincidence. But I don’t think so — I think the new policy helped.

It’s good that ER visits from the ill effects of over-the-counter cold remedies dropped for young children, but there still were too many of them — 1,248 in the sample hospitals. That’s a lot of risk for no benefit at all. For children over two years of age, there were nearly ten thousand ER visits for this problems. That concerns me just as much. Roughly two-thirds of the cases were ones in which unsupervised children took the medicine themselves, but fully a third of them were because parents gave the children the medication. My advice — don’t use these agents unless your doctor suggests them, and never in children less than four.

Every parent should know where to find the number of their local poison control center — it’s generally in the front pages of the telephone book. Call them if you have any questions about drug effects — they are always very helpful and you might save yourself and your child a trip to the emergency department.

Influenza vaccine is for everybody

November 26, 2010  |  General  |  1 Comment

Influenza, the flu virus, has arrived. It can be a serious infection, and it’s too soon to tell if this year’s epidemic will be as severe as last year’s was.

When I first started in medicine, influenza vaccine was generally only recommended for the elderly or those with some serious underlying condition involving their hearts or their lungs. That’s changed now, and for good reason: the higher the rate of vaccination in the population, the better the degree of herd immunity. For some infections, such as pertussis, a key to reducing the rate of infection is to stop its transmission among those who may only get mild cases, because that interrupts the chain of infection. Influenza is like that. The recommendation now is that nearly everybody should be vaccinated against it.

We also discovered last winter that the new so-called H1N1 strain of influenza could cause severe disease in otherwise normal people. For example, I cared for several children who required several weeks in the PICU on a mechanical ventilator before they improved.

The influenza vaccine is far from an ideal one. This is largely because the virus changes every year and the vaccine mixture needs to be tweaked annually to account for this. We have two types of vaccine — a shot in the arm and a mist blown up the nose. Depending upon you (or your child’s) age, the recommendations differ for which one you should get.

The national Centers for Disease Control (the CDC) explains the basis for their recommendation for near universal influenza vaccination here. It’s a bit heavy reading in spots, but it is the best expert opinion available on the matter.

The impact of children with complex chronic conditions on children’s hospitals

November 19, 2010  |  General  |  No Comments

I’ve been doing pediatrics since 1978, and over that time have seen a transformation of children’s hospitals. I trained at a then intermediate-sized one (Vanderbilt University Children’s Hospital), that has since grown into quite a big one. When I was a resident we had some children who had complex chronic medical problems, but they were in the minority. Most of the children in the hospital were there for problems that you could call bread-and-butter pediatrics. That situation has now changed, not just at places like Vanderbilt, but at all hospitals that care for children.

Over the past three decades we’ve made huge advances in pediatric care of children with complicated medical needs — premature infants, children with brain and spinal cord problems, those with severe respiratory issues, and many other categories. In the not too distant past, children such as these would not have survived beyond their early years; now many of them are becoming adults. Yet such children are often quite medically fragile, such as being susceptible to what would be minor infections for other children, and many are dependent on advanced technology to live.

These children need hospitalizations more frequently than do their peers who do not have such problems, and their increasing presence has had an impact on the population of America’s children’s hospitals. Two recent studies (here and here) document this evolution of what children’s hospitals do. It only covers a decade — 1997 to 2006. If it were cast back to the 1970s I’m sure the changes would be even more dramatic. The authors found that children with complex chronic conditions now account for 10% of all hospital admissions. However, they use 25% of all hospital days and 40% of hospital costs, numbers which reflect their complicated situations.

I don’t think these findings are unexpected or troubling in any way. Rather, they are a reflection of our success in allowing children who previously would have died to be part of their families, to participate in society. What is clear, however, is that as we plan for what it is that children’s hospitals do, we need to understand that more and more our role will be to care for these children. Young pediatricians completing their training also need to understand that, more and more, they can expect to have several such children at least in their practices. They need to be ready for that. This was also the conclusion of the authors of an excellent accompanying editorial: we need to be ready to give these children the care they need in the best place to receive it.

(Some of the links may only be to an abstract — if anybody wants the complete articles, and can’t obtain them, let me know.)