Recent Entries

My Thoughts on MAT in Jails

2019-05-08 12:26:30 jeffk2996

I recently ran across this news article on NPR (found here) about the problem of treating the large number of opioid addicted patients who are coming to our jails. There is a growing movement that all opioid addicted patients should be offered Medication-Assisted Treatment (MAT) while in jail--meaning one or more of three drugs: methadone, Suboxone or Vivitrol. The article does a good job in pointing out that this is a complicated problem. Having been on the front lines of this problem for many years in my own jails (and so having that great teacher--experience), I would like today to present my own thoughts on using MAT in jails. (MAT in prisons is a separate subject that I will address later).

Posted in: Drug EvaluationsDrugs of AbuseMedical PracticeUncategorizedWithdrawalTagged in: evidence based medicineinmatejailjail medicineJeff KelleropioidPrisonwithdrawal Read more... 6 comments

Shoulder Dislocations

2019-04-25 12:34:18 jeffk2996

NP here....What are your thoughts on shoulder dislocations? Does an anterior dislocation require immediate reduction? What if they go out to ED and come back dislocated again? It is thought that these offenders dislocate on purpose in order to go on a field trip. I have heard that anterior dislocations do not need to be reduced as they do not cause neurovascular problems. What has been your experience? Thought?  Thank you for your time!

Great topic! You have asked two questions here. The first question is whether shoulder dislocations need to be reduced immediately (since transporting a jail patient to the ER after hours can be a hassle) or whether the dislocation can wait until the next day to be reduced. The second questions is how to handle those patients who can dislocate and relocate their shoulders at will, and will use this trick to manipulate both the jail and ER staff.

Posted in: OrthopedicsSurgeryUncategorizedTagged in: evidence based medicineinmatesjail medicineJeffrey Kellerprisons Read more... 0 comments

Reader Question: How does a KOP Policy Work?

2019-04-04 12:13:12 jeffk2996

Hi Dr Keller,

I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? 
If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in  lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? 
Any ideas would be greatly appreciated!

After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them "pinched" from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as "sleepers" on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily? 

If you have any ideas I would greatly appreciate it.

Dez

Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. "In-possession" medications are referred to as “KOP,” which stands for “Keep on Person.”  I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:

Posted in: Drug EvaluationsDrugs of AbuseInmate issuesPharmacyUncategorizedTagged in: evidence based medicineinmatesjail medicinejailsJeffrey Kellerprisons Read more... 0 comments

Can the Oakland Raiders Be Saved Using the Principles of Medical Research?

2019-03-25 11:47:29 jeffk2996

One of my good friends is a die-hard Oakland Raiders fan.  Those of you who follow pro football know that Oakland has fallen on hard times recently.  They went from being one of the best teams in the league two years ago to one of the worst teams in 2018 with a dismal 4-12 record.  As a result, my friend has had to suffer taunts from fans of better teams—like me!  He has become despondent.

But it doesn’t have to be this way!  The Raiders can quickly and easily turn their season around by using the tried-and-true techniques of medical research.  If a pharmaceutical company did 16 clinical trials of their new potential blockbuster, Drug X, they would never let a 4-12 outcome get them down.  When published, I guarantee those trial results would look a lot better than 4-12.  The Oakland Raiders can use the same techniques to improve their own season record.

Change the primary endpoint!

Before a medical study begins, the researchers must identify exactly what it is that they are studying.  This is called the “Primary Endpoint.” For example, the researchers studying Drug X could initially decide that their primary endpoint is whether Drug X reduces mortality over five years.  What happens, though, if the study shows that Drug X did not, in fact, reduce mortality? What now? Well, often in that case, the researchers will scrutinize the study’s data to find out if Drug X showed some other benefit that they were not initially looking for.  Let’s say that patients taking Drug X had fewer DVTs.  This finding may have resulted purely by chance but what the heck!  They could publish a paper that says that Drug X reduces DVTs without, of course, mentioning that this was not the original primary endpoint of their study.  It turns out that this practice is common in published research papers and is called “Outcome Switching.” How common?  Well, according to this recent survey, outcome switching occurred in over 50% of the papers studied.

In a football game, the primary outcome is, of course, the final score. The Raiders lost 12 games in the 2018 season using the primary outcome of final score.   But if we look closely at each of these 12 games, we might be able to find, by chance, another potential outcome we could switch to.  Take, for example, when Oakland played the Indianapolis Colts on October 28th.  The Raiders lost that game 42-28.  But if we were to switch the outcome to the score at the end of three quarters, the Raiders win 28-21!  We’ll publish that as a victory without saying that we changed the primary outcome. Similarly, in their second game of the season, the Raiders lost to the Denver Broncos 28-20. But if we change the outcome to the score at halftime, we can publish this as a win, 12-0! We can do the same thing for their first game against the Los Angeles Rams.

After changing these primary outcomes, Oakland’s record has improved to 7-9. We’re on our way!

Use composite outcomes!

If a pharmaceutical researcher isn’t sure if Drug X will get positive results in any particular primary endpoint–like death, for example–they may instead add multiple other endpoints, hoping to get a hit on at least one.  The additional endpoints could include heart attacks, strokes, or anything else they can think of, like DVTS or even inpatient hospital days.  If any one of the many composite outcomes comes up positive, then the whole study can be published as positive. Of course, a DVT is much less important than, say, death, but since both are listed as equals in the composite endpoint, you would have to really read the fine print to find out if the “hit” was death or DVTs.  Composite endpoints are even more common in the medical literature than changing primary endpoints.  However, according to this article in the BMJ, the practice of using composite endpoints “will leave many readers confused, often with an exaggerated perception of how well interventions work.”

Composite endpoints turn out to be an immensely useful tool in re-evaluating the Oakland Raiders 2018 season!  My composite endpoints for the Oakland Raiders games are these: final score, total yards, first downs and time of possession.  I applied this composite endpoint to each of the remaining Oakland losses. Take, for example, the third game of the season against the Miami Dolphins. Oakland lost that game 28-20, but Oakland had more total yards, more first downs and a longer time of possession than Miami.  Clearly, we can publish this as a victory for Oakland using our composite endpoints.  Applying our composite endpoints, we can similarly change five other losses to victories.

Oakland’s record now is 13-3.

Simply don’t publish the negative results!

This has long been the easiest and best way to bury a negative trial.  Simply don’t publish it!  Negative studies in the medical literature have long been much less likely to be published than positive studies.  This “Publication Bias” has been such a big problem in pharmaceutical research that in 2004, many medical journals started requiring studies to be pre-registered in a Clinical Trial Database. This ensured that negative studies could be tracked even if they were not published.  So, is this requirement working?  Not so much.  According to this report, publication bias is still “alive and well.”

Publication bias can certainly help the Oakland Raiders.  Their revised 2018 season still includes three losses.  And all three were embarrassments where the Raiders got their butts kicked.  Take the October 14th game against the Seattle Seahawks, for example.  Not only was the final score a lopsided 27-3, but the Seahawks had far more total yardage, more first downs, more everything.  Let’s forget that debacle by simply not publishing it!  Let’s not publish the other two losses, either.

Oakland’s record now is 13-0.  However, we’re still not done.  The Raiders played 16 games, not 13.  We still have to find three other positive outcomes . . .

Publish a positive study more than once!

If a medical researcher has a positive study, it can be tempting to publish the results in more than one medical journal.  That way, the researcher gets two citations in their resume for the price of one!  There are two ways to do this. The first is to submit the same data to multiple journals without telling them you have done so.  “Duplicate Publication” like this is a form of fraud, but, as this medical journal editor says, “Duplicate publication is more common than you think.”

Another way to get a study published multiple times is to publish only part of the study’s data and then later publish the rest of the data in a second article. For example, in our study of Drug X, we could publish the data showing the effect of the drug on mortality first and then later publish the data showing the effect of Drug X on DVTs.  If the study is large enough and if the researchers slice the data thin enough, they can get many publications out of a single drug trial.

Let’s apply this principle to the Oakland Raiders. Their most impressive victory of the entire season was when they upset a very good Pittsburgh Steelers team–on the road, no less–on December 9th.  We certainly want to publish that twice!  Let’s also duplicate-publish the Raiders’ victories over the Denver Broncos and the Cleveland Browns. 

Well, we’re finished. The Oakland Raider’s final record after applying the principles of medical research is an undefeated 16-0!  My friend can break out the champagne and let the celebration begin! And to all of you other long-suffering Oakland Raiders fans out there—you’re welcome.



Do you agree with the concept of using the principles of medical research in sports? Please comment!

As always, what I have written here is my opinion, based on my training, research and experience. But I acknowledge that I could be wrong! If you disagree, please say why in comments!

A version of this article was previously published on MedPage Today.

Posted in: EditorialLab StudiesMed Page TodayUncategorizedTagged in: evidence based medicineinmatesjail medicinejailsMedical Researchprisons Read more... 0 comments

How to Write an ATP (Alternative Treatment Plan)

2019-03-15 15:31:38 jeffk2996

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Correctional Medicine UM is different. Those of us doing these evaluations are not being asked about payment; we are being asked for permission to do the procedure at all. We cannot simply deny the request like an HMO can. If we do not think the procedure should be done, then we must say what should be done instead: The Alternative Treatment Plan.

When done poorly, the ATP can irritate the primary care practitioner and even create an adversarial relationship between the practitioner at the site and the UM evaluator. When done well, the ATP is a written conversation between two equal colleagues and the ATP process can actually improve patient care.

Doing it wrong

Like any other bit of writing, it is important at the outset to define who your audience is. The ATP should be written with three potential readers in mind. The first is the site practitioner who made the initial request. A bad ATP will leave the PCP feeling underappreciated, threatened and disrespected: “I don’t trust you and you are stupid.” A good ATP will leave the PCP feeling like you are on the same team and that you have their back: “You’re doing great! Let me help you.”

The second potential reader of the ATP is The Adversary, like a plaintiff’s lawyer or an advocacy group. A bad ATP will indicate that you are denying the patient reasonable and necessary medical services. A good ATP will show that nothing was denied and will not imply that any medical service is off limits.

ATPs are also read by nurses, who have to transcribe and record the ATP in the official record. A good ATP will make their life easier. A bad ATP can result in many hours of needless, morale crushing busy work.

In my experience, it does not take much more time to write a good ATP instead of a crappy one.  Most UM evaluators, however, have never been taught how to write and ATP.  Here is how I write mine:

Step one: Restate what is being requested.

The first sentence of the ATP should briefly summarize the case and re-state what is being requested.

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen.

Step two. Support your ATP.

The next section of the ATP contains the evidence that supports your ATP. This evidence can be pertinent positives, like x-rays, labs, previous visits. This evidence can also be pertinent negatives, like incomplete exams or missing data. Finally, this paragraph can also include pertinent research that supports your ATP, such as a quote from Uptodate, RubiconMD or InterQual.

  • The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report.
  • There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in most cases of hematuria.

Step 3. The ATP should defer the request; not deny it.

It is important to never (or rarely) use the word “denied.” Instead, you should restate what was requested and then say it is “deferred “pending whatever you want done instead, such as “Pending receipt of missing information,” “Pending complete evaluation of the patient at the site,” or “Pending case evaluation in a case review conference”

  • Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site.
  • Abdominal CT is deferred pending complete evaluation of the patient at the scene.

Step four. Tell the Primary Care Practitioner what you want them to do instead.

The next sentence contains instructions to the site practitioner.  This is the “ATP” and should be labelled as such.  I also always date the ATP.

  • 3/11/2019 ATP: The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results.
  • 3/11/2019 ATP: The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).

Step five. State that whatever was requested can be reconsidered later.

I always add this last sentence as well, to reaffirm that I am not denying any medical care. “The request from the first paragraph” can be considered thereafter, if clinically appropriate or anytime if medically necessary.

  • Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate.
  • CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary.

Step six: Contact the PCP to let her know that her request was ATP’d.

I don’t think that PCPs should find out from a UM nurse that their request was ATP’d. They will feel much better about the process if you contact them. This also opens a method of communicating about the case if they have more questions. This can be accomplished with a simple email:

  • Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Putting it all together, here are the full ATPs:

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist. The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report. 3/11/2019 ATP: Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site. The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results. Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate. Email to PCP: Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen. There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in almost all cases of hematuria. 3/11/2019 ATP: Abdominal CT is deferred pending complete evaluation of the patient at the scene.  The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).  CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary. Email to PCP: Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Two more examples (minus email):

53 yo s/p treatment for tongue cancer in remission. Request is for routine FU with ENT at six months from last visit.
The patient has finished all of his radiation sessions. ENT note from 7/17 states that the patient is in remission and that the six-month FU visit is “prn.” The consult request notes no new symptoms.
3/11/2019 ATP: ENT consultation deferred. Per last visit with ENT, further visits are to be “prn.” The site PCP should evaluate the patient at 6 months from the last visit and again at one year from the last visit. Off-site visit with ENT can be considered thereafter, as needed–or anytime if clinically necessary.

62 yo who had a liver ultrasound as part of Hepatitis C staging. The ultrasound showed a hypoechogenic polyp or cyst at the neck of the gall bladder. The radiologist says “A CT may be of value.” There is no report that the patient is symptomatic. I submitted the case to a RubiconMD radiologist, who thinks this is an incidental finding and repeat ultrasound in 6 months is a better methodology to follow this incidental finding.
3/11/2019 ATP: Abdominal CT is deferred. Per RubiconMD radiologist’s recommendation, the site PCP should order a follow up ultrasound at ~6 months. CT may be considered thereafter as clinically appropriate (or anytime if necessary).

As always, what I have written here is my opinion based on my training, experience and research.  I could be wrong! If you disagree, please say why in comments.

A previous version of this article was published in CorrDocs, the Journal of the American College of Correctional Physicians

Medical plan

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