Healthcare rationing

[Gob]

it's the thin end of the wedge I tell you!

Consultants at one hospital have announced that they will refuse to accept GP referrals of patients who smoke.

Vascular surgeons from Edinburgh Royal Infirmary have defended their right to demand that patients stop smoking before accessing certain kinds of treatment.

The hospital, part of NHS Lothian, has argued that medical intervention for vascular disease could be avoided altogether if patients stopped smoking and adapted to healthier lifestyles.

Mr Zahid Reza, a consultant vascular surgeon at ERI, said that his clinic was refusing to accept GP referrals for patients who continued to smoke, unless it was an emergency.

He told the Scotsman: ‘Evidence shows that they would not do well with the treatment. In around 80% of cases, a smoker’s condition will improve just simply by stopping smoking and making other lifestyle changes.

‘Some patients have written to their MP demanding to see a consultant. I have written back to the MP to explain our position.’

NHS Lothian have denied the existence of a ‘blanket ban’ on refusing referrals, saying that each patient is treated on a case-by-case basis. However, Dr David Farquharson, medical director at NHS Lothian, said that some kinds of surgery had a lower chance of success, and that the chances of complications arising during surgery were higher for patients who smoke.

He said: ‘The best option can actually be to refer a patient into smoking cessation, fitness and diet intervention programmes to help them change their lifestyle, which will in turn improve their condition and if necessary the outcome of any medical intervention.’

But patient groups have attacked the decision, describing it as ‘shocking’.

Dr Jean Turner, a former GP who heads up the Scotland Patients Association, said that she was ‘extremely disappointed’.

She added: ‘You should not refuse to see anybody and certainly not penalise patients who are smoking. It is very God-like and highly unfair to refuse to see people referred from general practitioners.

‘If I was a GP I would be very angry. It’s not for a doctor to make a judgment. Doctors are there to see if they can help and relieve symptoms.’

A Scottish Government health spokeswoman said that a blanket ban on surgery for smokers was ‘not acceptable’ and denied that either the Government or NHS Lothian had proposed such a ban.

She added: ‘Smoking is never good for you. Patients who continue to smoke need to think very carefully about the increased risks involved, if surgery is being considered as a treatment option.’

[Long Run]

‘The best option can actually be to refer a patient into smoking cessation, fitness and diet intervention programmes to help them change their lifestyle, which will in turn improve their condition and if necessary the outcome of any medical intervention.’

Well, doesn't that explain a sizeable percentage of medical cases that have nothing to do with smoking? That kind of thinking is thick as five posts.

[Big RR]

So now the patients just won't admit they smoke; pretty silly, but I'd bet it's inevitable. Just what happens when doctors set up adversarial relationships with their patients.

[Long Run]

She added: ‘Eating too many unhealthy foods is never good for you. Patients who continue to eat too much need to think very carefully about the increased risks involved, if surgery is being considered as a treatment option.’

She added: ‘Excessive drinking is never good for you. Patients who continue to drink to excess need to think very carefully about the increased risks involved, if surgery is being considered as a treatment option.’

She added: ‘Having a sedentary life is never good for you. Patients who continue to be sedentary need to think very carefully about the increased risks involved, if surgery is being considered as a treatment option.’

etc.

[Gob]

So now the patients just won't admit they smoke; pretty silly, but I'd bet it's inevitable.

It's very hard to disguise that from a vascular surgeon.

[rubato]

You can test for cotinine. Only a moron would lie and think that they could get away with it.

Measure of cotinine exposure

Cotinine has an in vivo half-life of approximately 20 hours, and is typically detectable for several days (up to one week) after the use of tobacco. The level of cotinine in the blood is proportionate to the amount of exposure to tobacco smoke, so it is a valuable indicator of tobacco smoke exposure, including secondary (passive) smoke.[9] People who smoke menthol cigarettes may retain cotinine in the blood for a longer period because menthol can compete with enzymatic metabolism of cotinine.[10] African Americans generally have higher plasma cotinine levels than Caucasians,[11] males generally have higher plasma cotinine levels than females.[12] These systematic differences in cotinine levels were attributed to variation in CYP2A6 activity.[13] At steady state, plasma cotinine levels are determined by the amount of cotinine formation and the rate of cotinine removal, which are both mediated by the enzyme CYP2A6.[13] Since CYP2A6 activity differs by sex (estrogen induces CYP2A6) and race (due to genetic variation), cotinine accumulates in individuals with slower CYP2A6 activity, resulting in substantial differences in cotinine levels for a given tobacco exposure.[13]

Cotinine levels <10 ng/mL are considered to be consistent with no active smoking. Values of 10 ng/mL to 100 ng/mL are associated with light smoking or moderate passive exposure, and levels above 300 ng/mL are seen in heavy smokers - more than 20 cigarettes a day. In urine, values between 11 ng/mL and 30 ng/mL may be associated with light smoking or passive exposure, and levels in active smokers typically reach 500 ng/mL or more. Cotinine assays provide an objective quantitative measure that is more reliable than smoking histories or counting the number of cigarettes smoked per day. Cotinine also permits the measurement of exposure to second-hand smoke (passive smoking).

Drug tests can detect cotinine in the blood, urine, or saliva. Urine cotinine concentrations average fourfold to sixfold higher than those in blood or saliva, making urine a more sensitive matrix to detect low-concentration exposure.[14]

However, some smoking cessation programs contain Nicotine which will result in a positive for Cotinine presence. Therefore, the presence of Cotinine is not a conclusive indication of tobacco use.[15]

yrs,
rubato

[MajGenl.Meade]

Vascular surgeons from Edinburgh Royal Infirmary have defended their right to demand that patients stop getting ill before accessing certain kinds of treatment.

The hospital, part of NHS Lothian, has argued that medical intervention for vascular disease could be avoided altogether if patients stopped having peripheral artery disease and presented with much healthier lifestyles

.

Fixed

[Big RR]

rubato--true, but then people who are exposed to second hand smoke (as your post indicates), and those who vape with nicotine-containing products, may also exhibit elevated cotinine levels. Ditto for those using certain smoking cessation products. It may not automatically mean the person smokes.

And I doubt a person lying (or even telling the truth) would consent to his physician testing him to see if he is lying. Would you want to go to a physician who insisted on checking on the veracity of your statements? I wouldn't.

[Crackpot]

What about hspending already limited Heath care dollars fact checking patients?

[Lord Jim]

I think this is a splendid idea that should be expanded...

If doctors and hospitals limit themselves only to treating healthy people, think of how good their treatment stats would look, and how much money could be saved...

[TPFKA@W]

With respect to vascular surgeries the effects of smoking are more immediately detrimental than any of the other bad things people do for addictions. Most literally, were I to get a finger cut off and need to have it reattached I would be a prime candidate for that surgery because I don't smoke. They know if they reattach on me it has a good success rate. If I were a smoker it is likely they would not do it at all. When vascular surgery is performed it takes just one cigarette to cause a failure. ONE. That is how great the impact smoking has on your vascular system.

I get their logic.

[rubato]

With respect to vascular surgeries the effects of smoking are more immediately detrimental than any of the other bad things people do for addictions. Most literally, were I to get a finger cut off and need to have it reattached I would be a prime candidate for that surgery because I don't smoke. They know if they reattach on me it has a good success rate. If I were a smoker it is likely they would not do it at all. When vascular surgery is performed it takes just one cigarette to cause a failure. ONE. That is how great the impact smoking has on your vascular system.

I get their logic.

Makes sense. Wouldn't want to waste a perfectly good liver on an active alcoholic either.


Yrs,
Rubato

[Scooter]

Would anyone advocate giving a liver transplant to an active alcoholic, even assuming that alcohol abuse was not the cause of liver failure? How is this any different?

[Big RR]

Clarification of the question--is the person Mickey Mantle?

ETA--seriously, though, the difference comes from the scarcity of livers vs the scarcity of vascular surgeons. Certainly, if a resource is scarce it should be put to the best use it can; if it is not, there is no justification in refusing treatment to someone just because you don't like their lifestyle. No doubt smoking can affect the outcomes of vascular surgery, but this is far from a given; if the choice is to provide the treatment to a smoker who will have a low chance of benefitting from it or a nonsmoking, fit young person who will likely have a better outcome, then there is no question; but I don't see these services so limited yet that this sort of rationing is needed.

If we, as a society, want to limit healthcare expenditures on medical care to treatments reasonably calculated to be only above a certain outcome level, then let's do it openly and based solely on those outcomes and not on politically unpopular or popular behaviors/conditions that can negatively affect the outcomes. So the diabetic with some evidence of vascular problems would be denied the treatment in the same way that an obese person or smoker would. Perhaps Type A personalities with elevated blood pressure would be denied as well. And the elderly, who at best would benefit only for a short term of years, if at all, would similarly be denied treatment.

Somehow I don't see this happening because people will say that the net is so broad that I may get caught in it. But if we deny treatment to "them", the fat pigs or smokers that don't have the self control that we have, then it is something to be celebrated. Human nature, I guess.

[TPFKA@W]

If the payment source is the same for vascular surgery as it is for liver transplant surgery then the odds of the surgery succeeding should be taken into account in either case. Limited resources extends beyond organ availability. And yeah, it's going to suck for a lot of people.

[rubato]

Aside from the economic costs there is the whole "waste of time and life" in trying to fix someone who won't help themselves.

Doctors have feelings too and they don't like to waste their lives and time on people who want to die (or keep smoking which is the same thing).

If you would rather keep smoking than live than do so, and stop wasting our time.


yrs,
rubato

[Joe Guy]

If you would rather keep smoking than live than do so, and stop wasting our time.

There are very few smokers who would rather keep smoking than remain alive. I'd bet most smokers would at least attempt to quit smoking if a doctor told them a surgery will not be successful if they don't quit.

The pasted article is written in a way that exaggerates a problem that very likely is not widespread.

[Jarlaxle]

So...if my wife needs a knee replacement (very likely, at some point), will she have to give up the reason she needs a knee replacement? That being: a lifetime of exercise, running, and martial arts training.

For that matter: we both engage in a high-risk activity regularly...we ride motorcycles.

[Crackpot]

Well my dad has a artificial knee and hip and exercises regularly. In fact nowadays they start rehab immediately so there is no "downtime".

[TPFKA@W]

.we ride motorcycles.

God bless motorcyclists or else those on lists for transplants would be there forever.