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Posts Tagged ‘health care costs’

Back in 2013 I wrote a post about an accident I had with a horse which resulted in two broken metatarsals (the long bones in your foot). That post was about how healing takes time, and indeed, my foot did heal with time and patience.

 

Alas, it’s time to remind myself, again, that healing takes time…

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Goofing around on that fateful day… 

A few weeks ago I was out mountain biking with a friend. The irony of the story is that while we pushed ourselves to try out some new skills and sessioned a jump for a while, it was the relatively tame trail back to the car that had me hit the dirt. I can’t tell you what happened (I didn’t hit my head, thank goodness, I just have no idea what happened!) but as my hip and fist collided with the packed earth I was acutely aware that I’d broken something in my hand. In fact, my first words were “I’ve broken my hand” (repeated 3-4 times).

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My X-rays from 2013 needed arrows for emphasis. No arrows needed here: Spiral fracture of the 5th metacarpal and fracture at the base of the proximal 4th phalynx.

The doctor who saw me in the local Urgent Care was confident that I could continue working with my injury. Sure- I couldn’t suture or do some specific physical exam maneuvers, but otherwise I shouldn’t be too limited; at least that’s what he thought. Looking back on it, it wasn’t a smart decision to work with a bulky splint on my freshly-broken dominant hand. Yes, my brain was fully functional, but I could only examine patients using one hand, could only type with one hand, and had to use my left hand to use the mouse and navigate my computer (a task that required a surprising amount of focus- I couldn’t “drive” my computer and listen to a patient at the same time). Despite adding in some extra breaks and a brief stint having a nurse work in parallel with me it became obvious that I couldn’t carry on with work as usual.

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When my patients saw me in this they often said “It looks like you need a doctor more than I do!”. Another classic was “You’ve been in the wars!”. 

 

While I’ve working in the New Zealand medical sector for just over a year, this has been my first experience as a patient.

 

In my last post I wrote a bit about the healthcare system in New Zealand, but I didn’t mention how it’s all paid for and provided. I am no expert on the NZ health system, and the whole system is certainly more complex that I could (or should) spell out in a blog post, but the core organizations are the DHB (the district health board) which uses government funds to provide health care, ACC (the Accident Compensation Corporation) which is New Zealand’s Universal no-fault accident insurance scheme, and some private coverage (either paid out of pocket by patients or by optional additional health insurance).

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The DHB pays for medical care which is needed as a result of illness while ACC pays for medical care (and more) that is needed as a result of injury. The DHB only covers healthcare for citizens and those with working visas 2-years in duration, so if you are travelling (or working in NZ for less than 2 years) and become unwell you are financially responsible for your own medical expenses. ACC, however, covers everyone in New Zealand. If you are travelling in New Zealand and injure yourself you have access to healthcare through ACC. You may have to pay co-pays (For example $35+ for a GP or urgent care visit, $45 for an X-ray, and $20+ for physio visits), but if you have a massive accident requiring a helicopter ride and a prolonged ICU stay, you won’t get a bill…

 

ACC doesn’t just cover medical expenses, it also functions as disability insurance. If you can’t go to work due to an injury, they will compensate you at a rate of 80% of your normal income after one week. If you can go back to work part time they will help subsidize your until you are recovered and back to full time work. They have return-to-work programs, and try to get people back into the workforce in whatever capacity and quantity they are able.

 

ACC helps with other things: if you can’t drive they can provide taxis, if you can’t keep up with your daily tasks they get you in home help, if you need physio and strengthening they subsidize therapies and gym memberships, if you need counseling they cover that.

 

Essentially, ACC is a massive, national, accident insurance policy that is paid for by levies placed on employers, workers, and vehicles. Does the system have flaws? Certainly, what system doesn’t? There are people who defraud the system, and people will complain about declined coverage, but as a clinician and now a client I am very impressed with the system.

 

The day after my injury I was seen at urgent care where I paid $120NZD to be seen (this would be much less if I had a 2-year visa and was thus entitled to healthcare in NZ) and $45 for an X-ray. I then had a splint put on and a week later went back in for repeat X-rays, evaluation, and a more permanent splint at no additional cost. I’ve since seen the hand therapist and visited a physio twice because of a pain in my hip that wasn’t settling with time- both with a reasonable co-pay. I worked for a week with my initial injury, but came to realize that I wasn’t able to doctor one handed and in a splint, so after talking with my boss it was decided that I’d be off work while I was in my current splint and limited to the use of my non-dominant hand. ACC promptly recognized my claim and called me to see if I needed help getting to appointments, help around the home, and what was appropriate compensation while I couldn’t work (information based on last year’s tax return). Thinking about what my ACC levy was last year and what it’s likely to be this year I suspect I’ll get about as much out of ACC as I put in. I’d be very happy if I hadn’t had to use their services, but I’m incredibly glad that a national accident insurance exists in NZ*.

 

I’ve extended my time in New Zealand through March but plan to return to the United States to work and live after that. As I start to mentally prepare myself to return to the US and think about working in a for-profit healthcare system, I find myself already missing the public health system in NZ.

 

5 years ago, when I broke my foot, even though I had medical insurance I ended up owing over $2000 out of pocket for a single, simple, medical encounter.

 

For one medical encounter where I was evaluated, X-rayed and given a walking boot and crutches the total bill was well over $5000USD. The old orthopedist who walked in and said “Doctor, heal thyself!” sent a bill for $2479, including global billing codes for evaluation and treatment of 2 fractured metatarsals (at $1027 a pop, or perhaps I should say a hair-line crack), despite needing no treatment other than protection in a medical walking-boot. My foot healed with time, and my hand will heal with time, but it is high-time that the US figures out how to provide affordable healthcare for its people.

 

(*This also has huge implications in “Treatment Injuries” and physicians are not sued for huge sums as they are in the US in the case of adverse outcomes, but that is more than I care to go into today!)

 

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My dad writes good get-well cards…

 

 

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This one isn’t exactly “evolutionary medicine”, but it sure is a smart, cheap, and (in my experience) unheard of little tip for shortening hospital stay (and thus cutting the bill) for some surgery cases.

Surgery comes with innate risks. Bleeding and infection can occur with any surgery, but operations that affect the bowel come with additional risks and concerns. One frequent complication of abdominal operations is postoperative ileus- a temporary paralysis of the intestinal tract after surgery that is usually related to the degree of surgical trauma and bowel manipulation.

When you are part of the surgical team, an important part of post-surgical care is keeping track of the workings (or lack thereof) of the patients’ digestive system. A typical morning check-up on a patient might go something like this:

“Hello! How are you feeling this morning?” (This exchange usually takes place around 5:30 in the morning… Anyone who says “good” is obviously bluffing!

“Sleep well?” (I think I may be the only student that cares about this question.)

“Any pain?”

“And have you had a bowel movement? No? Ah- have you passed any gas? Above or below?”

Yes, when you enter the world of medicine, the taboos of normal conversation (indeed, many social graces) are quickly forgotten.  Gone are the tendencies to giggle when someone says “fart”. Instead, the return of a patient’s bowel function can become a celebrated event amongst the team.

Post operative ileus is likely caused by a number of factors, including increased sympathetic activity (the fight-or-flight side of our autonomic nervous system) which overpowers the parasympathic (the rest-and-digest) system, as well as inflammatory mediators.  Additionally, some of the drugs that are used before, during, and after surgery may also inhibit bowel motility [1].

Ileus can delay patient recovery and increase the length of patient hospitalization, which leads to greater healthcare care costs. So how can we decrease ileus?

There is some evidence to suggest that therapies such as early postoperative mobilization (getting up and walking) and early feeding may decrease post-operative ileus [1].  I’m particularly interested in early post-operative feeding, which seems to come with a host of benefits in comparison to “NPO” (nil by mouth) that is common after surgery.  In fact, in a meta-analysis of 11 studies including 837 patients, early post-operative feeding significantly reduced the risk of any type of infection and reduced the mean length of stay in the hospital.  It also reduced (though not statistically significantly) the risk of anastomotic dehiscence (the breakdown of the site where bowel was sewn together), wound infection, pneumonia, intra-abdominal abscesses, and mortality. The down-side of early post-operative feeding is that the patients have an increased risk of vomiting [2].

But is there a way to get the benefits of early feeding without the risk of vomiting? Is there a cheap and easy way to increase the rate at which bowel function returns?  It appears the answer is yes, and it is incredibly cheap and easy: Gum.

Gum chewing works as a type of sham-feeding that promotes intestinal motility. It seems that chewing gum causes our brain to pass the signal to our stomach that food is on the way. In normal volunteers, gum chewing stimulates gastric secretions. In patients, gum chewing appears to wake the GI tract up more quickly than if their mouth stays idle [1].

A meta-analysis of 9 trials including 437 patients showed a reduction in time to first flatus (the medical term for fart), time to first bowel movement, and reduction in hospital stay in patients in treatment groups versus controls. The treatment groups chewed sugarless gum at least three times a day for 5-45 minutes starting on the first post-operative day [1]. While early post-operative feeding seems to offer a number of benefits in comparison to fasting, it can be poorly tolerated and only taken in small amounts. Chewing gum is a method of sham-feeding that stimulates bowel activity, without the possibility of vomiting or the limited intake of food seen in some patients.

I have heard surgeons at our University talk about the data regarding early-feeding. I have not heard anyone talk about the benefits of gum chewing.  The data is out there, but unlike pharmaceutical interventions which have drug-reps proclaiming their benefits, simple interventions such as these are not widely promoted.  Who would benefit from promoting this information?  Even if every hospital ward in the country started stocking gum, I doubt the gum-makers would notice an uptick in their bottom line- this isn’t exactly a high dollar intervention. In fact, the meta analysis suggests that chewing gum can reduce the length of hospital stay by a mean of approximately 2 days at the average cost of $0.60 per patient [1].

It is important to mention that many of the studies included in the meta-analysis were conducted in Africa, where the risk of complication and the subsequent length of stay are much higher than in the US.  While on my surgery rotation, I saw some patients go home less than 24 hours after having their appendix removed. One paper from 2006 shows that the mean hospital stay after appendectomy at a teaching hospital in South Africa was 10.6 days [3]. Indeed, much of the primary data that I read about surgery in the developing world leaves me cold.

Laparoscopic surgery (performed through small incisions in the abdomen and visualized with a small camera), means that simple procedures such as the removal of an appendix or gallbladder can be done with minimal trauma and scarring. In developing countries, these operations are still done with open incisions, in operating rooms that lack many of the most basic tools necessary for good surgical care.

Angela’s recent guest post has inspired me to think more about the great disparities in health, disease, and medical care in the developed and the developing world.  As I read more about surgery and medical care in Africa, I realize that even the simplest of interventions can have a huge impact on health care, especially in developing areas. This was also brought through in Atul Gawande’s book The Checklist Manifesto, which I read recently.

It is unrealistic to think that hospitals in developing nations will be equipped with cutting edge technology to perform minimally invasive surgery any time in the near future. Such technology is expensive, and it requires surgeons who have been trained to use it (not to mention reliable sources of electricity to power the equipment).  Yet simple solutions, such as post-operative gum chewing, can offer serious benefits that should not be ignored [4].  And if I find myself on the other side of an early morning post-op check-in, I know I’ll be requesting something to chew on*!

*It should go without saying that this post is not meant as specific medical advice, but as an exploration of a potentially useful therapy that doctors should consider. If you find yourself on the wrong side of the operating table, work with your medical team to get yourself on the road to recovery ASAP.

 

1.            Noble, E.J., R. Harris, K.B. Hosie, S. Thomas, and S.J. Lewis, Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg, 2009. 7(2): p. 100-5.

2.            Lewis, S.J., M. Egger, P.A. Sylvester, and S. Thomas, Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ, 2001. 323(7316): p. 773-6.

3.            Ayoade, B.A., O.A. Olawoye, B.A. Salami, and A.A. Banjo, Acute appendicitis in Olabisi Onabanjo University Teaching Hospital Sagamu, a three year review. Niger J Clin Pract, 2006. 9(1): p. 52-6.

4.            Ngowe, M.N., V.C. Eyenga, B.H. Kengne, J. Bahebeck, and A.M. Sosso, Chewing gum reduces postoperative ileus after open appendectomy. Acta Chir Belg, 2010. 110(2): p. 195-9.

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