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Doctors Who Speed; Hospital Care at Home: It’s PodMed Double T!

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include physician driving behavior, obesity projections by state, hospital at home, and marijuana vaping by youth.

Program notes:

0:41 Vaping in American youth

1:40 53% reported using marijuana via vaping

2:41 Sentiment that it’s safer

3:22 State-by-state projections on obesity

4:23 Used NHANES data to validate

5:30 Most self-reporting underestimate

6:30 One in two obese in the next decade

7:00 Hospital at home

8:00 40% lower than hospitalization

9:00 4 in 10 were willing to be randomized

9:43 Physician driving behavior

10:43 Psychiatrists got tickets most often

11:40 Physicians talk their way out of a ticket

12:58 End


Elizabeth Tracey: State-level prevalence of adult obesity and severe obesity projections.

Rick Lange, MD: Delivering hospital care at home.

Elizabeth: What do we know about physician driving behavior?

Rick: And marijuana vaping by our youth.

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on December 20th, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, a little break here. We’re going to start with you and I think why don’t we start with the vaping? That was from two research letters in the Journal of the American Medical Association.

Rick: These are self-reported marijuana use and electronic cigarettes among youths over the time period of 2017 to 2018. As you noted, there were two reports, and both of them I find very alarming. The first one was the National Youth Tobacco Survey. It’s a cross-sectional, school-based survey, and it’s conducted annually among middle schoolers and high schoolers. About two-thirds of the students who were invited to participate in the survey did, and the question they asked, there were two questions. One is have they ever used marijuana in an e-cigarette and then the other study they asked how often they had used marijuana in an e-cigarette in the last 30 days.

What they discovered is from their sample of over 38,000 students, about a fourth of the students had ever used e-cigarettes, and about 11% were current users. And among those, about 53% reported that they had ever used marijuana as a part of the e-cigarette. That’s pretty alarming. That’s over half. The other question posed in the other survey was what percentage had used it within the last 30 days? Among 12th graders, 14%. Why is that concerning? There are concerns about brain development and cognitive function, but also the recent reports we’ve had of over 2,300 vaping-related lung injury cases and over 47 deaths as well. That’s just at the end of November. The absolute increase of the marijuana vaping among 12th graders over the last 30 days is the second-largest single-year increase ever tracked. The largest increase was an increase in nicotine vaping between 2017 and 2018.

Elizabeth: I’m not sure exactly what we can do about this issue because I think the perception is — and this has been a perception that’s been out there since these devices came on the market — that somehow it’s safer to vape things that one wants to inhale rather than, frankly, smoke them, and I suspect that that’s out there with regard to cannabis products also.

Rick: You’re right. They need to be aware that it’s not harmless. Vaping is not harmless, especially when you’re vaping non-nicotine substances. The last thing is they need to be regulated, and as you know, there’s a huge swell of enthusiasm for not allowing anybody under the age of 21 to be exposed to these things.

Elizabeth: I would just note that there’s another report that just came out looking at the consequences of vaping among a large population of adults using these devices and establishing that there’s any number of chronic lung diseases that do result from vaping, so the data is emerging clearly that this is not an innocuous practice.

Since we’re talking about things that are alarming, let’s turn to the New England Journal of Medicine, and I was quite alarmed by this. This was a special article that took a look at state-level prevalence of adult obesity and severe obesity.

This is a projection and what they did was, they looked at a really kind of an interesting, something I didn’t know about database that’s out there, the Behavioral Risk Factor Surveillance System Survey, where they routinely query people about various behavioral risk factors. From looking at that data between 1993 and 2016, they were able to get over 6 million adults represented in that particular database, and then they also looked at 57,000+ adults who participated in NHANES. We’ve talked about that many, many times, and then they took those two together and they said, “How can we correct for this self-report from the Behavioral Risk Factor Surveillance System Survey?” And they used the NHANES’ data in order to validate everything that they were doing.

They said, for each state, “What’s our estimate of the prevalence of four BMI categories from 1990 through 2030?” The very daunting projection is that by 2030 almost 1 in 2 adults will have obesity. The prevalence will be higher than 50% in 29 states and not below 35% in any state, and that nearly 1 in 4 adults is projected to have what they’re calling “severe obesity,” what we’ve called in the past “morbid obesity,” so a BMI greater than 35. The prevalence of that will likely be higher than 25% in half of the states in the United States. Lots and lots of numbers.

Basically, also, there are certain ethnic groups and minorities and women who are going to experience a disproportionate amount of this and a very, very persuasive table, so I refer our listeners to the text on this one that looks at each state itself and says, “This is what it looks like it’s going to look like in 2030.”

Rick: Elizabeth, you’re right. The key feature of this is most self-reporting studies underestimate the severity of obesity because we tend to underreport our weight, but when they combined that with the NHANES data, which is clearly objective data, they’re able to correct for that, and the figures that you state are absolutely alarming. One in two individuals in the U.S. over the next 11 years will be obese, with the vast majority being severely obese, and it varies by state.

Elizabeth: I thought one of the pieces of information that was interesting from this was that the prevalence of severe obesity is highest among those who have incomes of $20,000 a year or less.

Rick: That has to do with, I think, some food availability. Some of it has to do with education. We need to be promoting a healthy weight over someone’s entire life. It needs to start in school at a very young age and continue throughout school as well. And we need to have some policy and environmental interventions at the community level. We’ve been talking about this for the last decade or two. We need to seriously intervene. Knowing that 1 in 2 Americans will be obese in the next decade is the biggest health problem I think addressing America right now.

Elizabeth: And the authors project just how much with regard to healthcare costs, especially now that a lot of interventions like bariatric surgery are being paid for by Medicare and Medicaid. It could bankrupt the system.

Rick: And not only the obesity, but the associated conditions like hypertension, diabetes, cardiovascular disease, cerebrovascular disease. Thanks for picking this particular article, Elizabeth.

Elizabeth: Yeah, something else to worry about at night. Let’s turn to Annals of Internal Medicine. This is one that I actually like and I like it from the humanistic perspective. But this was taking a look at can we provide hospital-level services at home and what’s the impact of that?

Rick: This is important because about a third of all health care expenditures are related to inpatient care. Inpatient care is expensive. What this study tried to address is when these patients come into the emergency department, instead of admitting them to the hospital to receive their care, can we deliver the same quality of care at home, and if so, can it be less expensive than hospital care?

So this is a randomized controlled trial done in an academic medical center and a community hospital based in Boston. There were 91 adults; 43 were referred for homecare after coming to the emergency department, and 48 received the hospital care. Acute care at home included nurses and physician visits, intravenous medications. Interestingly enough, remote monitoring of the patients, so they could monitor their heart rate and their blood pressure and their oxygen and whether they were falling or not or whether they were ambulatory.

The mean adjusted cost of the acute-care episode at home was about 40% lower than it was for patients admitted to the hospital. By the way, they didn’t include physician costs, but the patients at home, they were less likely to have extra radiology procedures and laboratory orders. They had better ambulation and about the same hospital stay.

Elizabeth: It’s clearly something that I would love to see expanded to many hundreds, even thousands of patients, to see how practical this could end up being. I thought that the reduction in the number of studies and all kinds of interventions was really pretty impressive. And the other part that didn’t get addressed here is what about what the patients thought of it?

Rick: As you noted, it’s a relatively small study, so it’s hard to address the quality of care and safety of care, but you’re in your own environment, your own setting. People aren’t waking you up in the middle of the night. You’re sleeping in your own bed. You’re in the comforts of home. Other studies have suggested that people would rather receive their care at home, if possible.

Now interestingly enough about this particular study, only about 4 in 10 individuals that qualified for the study actually were willing to be randomized. About two-thirds of the patients who were offered this study declined not to receive their care at home, and obviously, you’re not going to take care of the sickest patients at home. Now these patients could have heart failure or lung disease or could have an infection that required intravenous antibiotics, but they weren’t the most severe patients that would typically be in an ICU setting.

Elizabeth: Right, I think those points are well taken. I would just also note that every time I talk with people they say they’d rather be at home. So I think if there’s some way that we can help them to achieve that goal that’s a good thing.

Rick: I think so and so this needs to be expanded to a larger population, but I can tell you in other countries, particularly in Australia and Spain, they have adopted delivering hospital care at home to a much larger extent than we’re doing in the U.S.

Elizabeth: Good news. Now, let us turn to a much lighter note, the British Medical Journal, of course, publishes a Christmas issue every year. And this year, from the Christmas issue, we’ve selected a paper that’s entitled, “The Need for Speed: An Observational Study of Physician Driving Behaviors.” The study was limited to driving behaviors and just in Florida, so there’s some bias that’s inherent in that right off the bat and I’ll admit that. They had over 5,000 physicians and almost 20,000 non-physicians who were issued a ticket for speeding between 2004 and 2017. They looked at speeds greater than 20 miles per hour. That was similar between physicians and their sample population, and the number who actually received a ticket for speeding was also very similar between the physician population and the non-physician population.

Who is it who got the tickets most often among the physicians? It turns out that it was psychiatrists who got it for extreme speeding. They were the most likely with a baseline specialty of anesthesia as a comparator. Among the drivers who received a ticket, luxury car ownership was most common among cardiologists in this particular cohort and least common among ED docs, family practice, pediatrics, general surgery, and psychiatry. I thought it was really interesting indicting some cardiologists, at least in Florida.

Rick: I had to laugh when you picked this out. Many of our listeners may not know that I am a cardiologist, by the way. In full transparency, I haven’t had a speeding ticket in over 20 years. Now, it doesn’t mean I didn’t deserve one. I just didn’t have one in the last 20 years. I thought it was interesting. This was a study conducted by Harvard. You’d think they’d pick on Boston drivers. No, they picked on Florida drivers is what they did.

One of the things I thought was interesting was I would think that physicians would be able to talk their way out of a ticket. The policemen would be more lenient for physicians either because they’re heading to the hospital or because many policemen are taken care of by physicians, but in fact, they were no more lenient toward physicians than they were towards non-physicians. It didn’t really help to tell them, “Oh yes, I’m a doctor.” He said, “Well, thank you very much. Here’s your ticket.”

Elizabeth: A couple factors that weren’t surprising to me at all. Male sex and younger age were statistically significantly associated with extreme speeding, and here’s a fact of note. The need for speed record belonged to a general internist who was clocked in at over 70 miles per hour above the posted speed limit. That’s happenin’.

Rick: Busted! That guy clearly needs a ticket. I don’t even know where you’d drive where you go 70 miles an hour over the speed limit. It was a fun article to report on. What I would tell our listeners is make sure that over the holidays you have a very safe holiday.

Elizabeth: That’s right. On that note, then, that’s enough about the cardiologists who speed. Merry Christmas and we’ll be talking to you before the New Year. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.