3 Macrovascular Risks of Uncontrolled Diabetes Mellitus

Uncontrolled diabetes mellitus (either type 1 or type 2) is associated with several complications caused by the chronic damage that excess glucose causes to the tissues of the body. The vascular tissue, is particularly sensitive and leads to the damage of organs as we are going to see.

Coronary Artery Disease (CAD). Diabetics have a higher rate of heart attacks than the general population. Excess glucose over many years contribute to the generation of atherosclerosis and the formation of plaques in the coronary arteries that will eventually be the cause of the heart attacks. Heart attacks, are also the main cause for heart failure and sudden death.

Cerebrovascular Disease (CVD). A similar problem in the vascular system of the brain is responsible for the appearance of more strokes in diabetics than in the general public. In this case, the atherosclerosis and the plaques are formed in the carotid arteries and the arteries of the brain. Debilitating strokes, and dementia are the main consequences.

Peripheral Artery Disease (PAD). If the atherosclerosis and plaque formation happens in the arteries of the lower extremities, the consequence may be the amputation of different parts of the leg. These can range from losing toes to the loss of an entire limb. It is well known that diabetics have a higher incidence of amputations than non-diabetics

Strict control of the blood sugar is the mainstay of the prevention of these complications. To get to the point of a heart attack, a stroke or an amputation, decades of elevated blood sugar have to be present. In addition, other factors such as smoking, high blood pressure, or genetic predisposition can speed up the process of atherosclerosis. There are many options to control the blood sugar, including many pharmacologic measures such as oral medications and injectables such as insulin and non-pharmacological measures such as diet and exercise.

Marco A. Ramos MD

Tips for Great Clinical Documentation Part 1.

As I explained in the previous post of the series, Clinical Documentation Improvement (CDI) is a recognized process of improving records to ensure improved patient outcomes, data quality and accurate reimbursement¹. In order to achieve great documentation before the need for a Clinical Documentation Specialist (CDS) queries a medical provider, there are some tips that are usually useful. In this post I will present a few of these, with more tips coming in the next post.

Be Specific

By being specific I mean, to describe the condition as much as you can un terms that are accepted by all practitioners and coding specialists. For example, you should always indicate the stage of a condition, e.g, it is not enough to document chronic kidney disease (CKD) alone. It is important to say if this is a stage III, or a stage IV CKD. Treating a more severe condition, represents that more resources are being used because the patient is sicker. Also, the type of condition that the provider is dealing with is necessary to be known, for example, if the chronic heart failure is of a systolic type or a diastolic type. Treatment, may be different between those conditions and establishing the difference might have an impact in retrospective research. Finally, specifying the chronicity of an illness (acute or chronic) is important. An example of this is anemia. Having a hemoglobin concentration of 7.0 g/dL is different if this is a consequence of a gastrointestinal hemorrhage or if this is a level that has been maintained for years, like in patients with sickle cell anemia. The first patient will need a gastroenterology consultation with a possible endoscopic procedure, the second patient will need careful monitoring and possible advise from a hematologist.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation

References

1. https://en.wikipedia.org/wiki/Clinical_documentation_improvement. Retrieved June 2, 2016

Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

The Importance of Clinical Documentation Improvement

Clinical Documentation Improvement (CDI) is the recognized process of improving healthcare records to ensure improved patient outcomes, data quality and accurate reimbursement¹. The effects of having a good CDI program are multiple and they include excellent record keeping for future chart review, (especially beneficial in medical research and legal discovery processes), great communication amongst healthcare providers and better resource consumption and length of stay.

An essential part of the CDI process is the role of the Clinical Documentation Specialist (CDS). The CDS is usually a registered nurse (RN) who has specialized in documentation compliance and integrity. The CDS is trained to identify records that may be lacking the specific language needed to support the documentation standards as defined by insurance companies, research protocols and the legal system. The CDS will query the healthcare providers associated to the chart to look for clarification, avoiding at all times leading the healthcare provider towards a specific diagnosis.

The query is the way the CDS communicates with the healthcare provider. It is framed as a question with background information and a request for an action which is usually an agreement or a disagreement with the question. Queries are important because the help clarify terminology so that the medical record accurately reflects reality. The timeliness of a response to a query is very importance because the closer the gap in time between the generation of the query and the response, the more better the response will reflect reality.

The CDI program is usually enhanced by a physician advisor or medical director, who is in charge of advising the CDS, generating education processes and increasing compliance with the query answering process.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation

References

1. https://en.wikipedia.org/wiki/Clinical_documentation_improvement. Retrieved June 2, 2016

5 Possible Consequences of Uncontrolled High Blood Pressure

Uncontrolled high blood pressure (hypertension) is associated with several health conditions. Hypertension is treatable, so this means that the following diseases can be prevented or delayed. 

1. Heart attacks. Elevated blood pressure is related to atherosclerosis, which, by narrowing the coronary arteries, can lead to heart attacks. Heart attacks can cause congestive heart failure and sudden death. 

2. Impaired vision. Hypertension can cause something called hypertensive retinopathy. This means that the retina (where the images are formed in the eye) can get damaged by chronic high blood pressure and can lead to impaired vision and blindness.

3. Amputation of limbs. High blood pressure can lead to the amputations of limbs, specially feet and legs. The problem starts with the atherosclerosis in the arteries of the limbs which eventually leads to obstruction and lack of blood supply to the feet and legs, especially. Hypertension is related to the atherosclerosis of the limb arteries, just as with the heart.

4. Stroke. The brain can also be the victim of atherosclerosis, which is related with hypertension (as we have just seen). In addition to this, if the blood pressure becomes too high, it can lead to bleeding inside the brain, by rupture of the arteries.

5. Kidney disease. The kidneys are very sensitive. Elevated blood pressure for a long time can cause scarring of the kidney tissue to the point that it cannot perform its functions anymore. The kidneys are important for sodium and potassium control, blood pressure control, generation of red blood cells, vitamin D and calcium metabolism and acid-base balance.

Marco A. Ramos MD

Alzheimer's Disease Genetics Explained

Alzheimer’s Disease (AD) is a chronic degenerative disease of the brain which leads to progressive dementia, which is the loss of the mental faculties of a person. Memory, personality, judgement and reasoning can get severely impaired. The development of AD has a strong genetic component, which may be complicated to understand, but I will try to simplify it here.

There is a gene called APOE. This gene encodes a protein called apolipoprotein E. There are 3 variants of the APOE gene (ε2, ε3, ε4). Each of us inherits 2 variants of the gene, so we all are either ε2/ε2, or ε2/ε3, or ε3/ε3, or ε3/ε4 or ε4/ε4 or ε2/ε4. 

The combination ε4/ε4 has the highest possibility of AD. According to one study, at 85 years of age, people with this combination would have a possibility of 51-52% of developing the disease if male, and 60-68% if female. The combination with the lowest possibility is ε2/ε2, it has a 4-5% possibility of AD if male and 6-8% if female. All the other combinations are in between.

It is important to note that this gene is not the only one associated with AD. If you know your particular combination, it is best to consult a healthcare provider for proper advice.

Marco A. Ramos MD

Further reading here:: http://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&term=9343467

3 Important Things Patients Need to Know About Telemedicine

Technology is improving and advancing fast. What was impossible just a few years ago, is becoming possible now. Nowadays, a physician can see a patient, interview him or her, auscultate, examine the skin, prescribe medications and document in an electronic medical record, without being physically by the patient’s side. 

The first issue that needs to be brought up is the location of the medical act. It has been defined that the medical act occurs where the patient is located. This has consequences regarding licensing and regulations. As it is well known, in the United States, licensing goes state by state, so the physician has to be licensed in the state where the patient is located. This means that, so as the doctor is licensed in the state where the patient is located (and the state medical board is OK with it) the physician can be located anywhere in the world and see, listen and treat a patient.

A second issue is the question of insurance reimbursement. As of today, not all insurance plans reimburse for telemedicine services, although this is increasing by the day. The patients have to be aware if a service rendered by telemedicine will be reimbursed by a particular insurance plan if not paying out of pocket.

The third issue is that there are some specialties that are more ready for telemedicine, than others. For example, Neurology and Psychiatry have been using this services for some years. The surgical specialties (due to the nature of their service) have not quite embraced it yet. It is not impossible to think that in the future, a surgeon might operate remotely, using devices similar to joysticks.

Marco A. Ramos MD