Dr. Ronan Kavanagh

Archive for January, 2012|Monthly archive page

Internet usage in Irish Medical patients – A survey

In Uncategorized on January 19, 2012 at 5:21 pm

As we are on the verge of moving over to an online appointment booking system and extending the use of texting to patients in our practice, we recently undertook a  survey of our patients. Over the last week, patients in our practice have been patiently completing questionnaires regarding their use of mobile phones, texting and internet usage. Thanks to all of those who took the time to do the survey.

These results apply to a special and limited section of the population and may not be applicable outside of the setting of a private rheumatology outpatient clinic and should be interpreted in this light.

We surveyed all patients presenting to the outpatient clinic of two rheumatologists (Dr. Adrian Gibbs and Dr. Ronan Kavanagh) over a one week period. 124 patients completed the survey.

The patients surveyed are that bit older than the general population (Median 57 yrs vs 34.8% nationally), more likely to be female (2/3 are women vs 50% in the general population) a bit more affluent than average (there is some data to suggest that internet usage is higher in those with higher incomes).

Even allowing for the fact that our patient population is higher than that in the general population, the results of this survey show that mobile phone, texting and internet usage is high amongst patients attending our clinic.

Here’s a summary of the results.

  • 96% of our patients have a mobile phone
  • 84% are able to send and receive text messages
  • 72% of our patients have internet access
  • 70% of our patients who do not have internet access indicated that they a family member who accessed it on their behalf
  • 41% of our patients are on Facebook and 18% on Linkedin and only 5.3% have Twitter accounts
  • 83% of our patients send or receive emails daily or a few times a week
  • 79% have researched a product or service online
  • 83% have looked online for information about a specific disease
  • 70% have looked online for information about medical treatment or procedure.
  • 59% have looked online for information regarding health insurance
  • 56% of those with a Facebook account post updates daily or a few times a week and 44% post rarely of never post.
  • 88% of those who had visited the Arthritis Ireland Website indicated that they thought it was either good or excellent
  • None of our patients have ever posted an online review of a doctor and only 2.5% have posted a review of a hospital online.

The majority of our patients have a mobile phone. Whereas 84% of patients indicated that they are able to receive AND send messages, it is possible that had we asked the question in two parts, there would have been greater percentage of patients who knew how to receive / read text messages.

The internet usage in our patients is very similar to that in the general population. 72% of our patients use the internet and 69% of Irish households have internet access. Only 41% of patients who use the internet indicated that they have a Facebook account compared with the 69% of Irish internet users (or 45.3% of the Irish population). This probably reflects the older average age of our patients. Also of those who have a Facebook account 25% rarely post and 20% never post messages (figures are similar for Linkedin users with 51% posting daily or a few times a week).

Many of our patients have researched a product or service online and most have looked online for information about a specific disease,treatment or procedure but very few patients have looked at doctor or hospital ratings websites and none of them have rated their doctor in an online ratings site.  Irish internet users, it would seem, are internet ‘Lurkers’ and like to watch rather than post updates or comments.

Overall, the results of this survey suggest a high proportion of our patients will be in a position to avail of an online booking system when put in place. Whereas we have had a text reminder service for all outpatient appointments for the last few years, until now we did not know what percentage of our patients might be able to avail of it. We are now going to extend this to annual recall appointments and where possible send  dual reminders by text and email.

Summary graphs appear below

The Weather, Arthritis and Woody Allen’s Orgasmatron.

In Arthritis and Rheumatism, Osteoarthritis, rheumatoid arthritis, Uncategorized, Weather on January 9, 2012 at 4:36 pm

Woody Allen’s 1970 movie ‘Sleeper’ introduced its audience to a fictional, futuristic device called the Orgasmatron. This remarkeable invention was capable of inducing physiological changes (of a pleasurable kind) in those placed within it. I sometimes wonder how much Woody Allen’s contraption was influenced by a device with a similar name from the early 1960’s in which the earliest scientific experiments on the effects of weather on arthritis symptoms were performed.

The Orgasmatron in action

The Climatron, as it was referred to in media reports of the time, was used by Professor Joseph Hollander, a Philadelphia based rheumatologist to determine the effects of the weather elements on the symptoms of arthritis patients. The device was basically a hotel room sized chamber (with room service) which was designed to comfortably house two patients for periods of two to four weeks. Using a system of valves and dials, it was possible to adjust the temperature, humidity, rate of air flow, barometric pressure within the chamber.

The Climatron in action (with Prof Hollander)

In his experiments, a small group of largely ‘weather sensitive’ arthritis patients, were recruited to come and stay in the Climatron. A number of times a day they completed a diary documenting various aspects of their health including assessments relating to their joint symptoms. They were also examined by a doctor and had their joints assessed. None of the subjects were aware that the main focus of the research was their joint symptoms and were not informed about changes being made to the weather variables within the chamber.

When individual weather variables were adjusted in the Climatron, none of the subjects  noted any difference in their joint symptoms. However when an attempt to reproduce the weather conditions of imminent stormy weather (simultaneous increase of humidity and reduction in atmospheric pressure) the effect on symptom worsening was significant in 7/8 of the rheumatoid patients and in 4/4 of the osteoarthritis patients. When this experiment was completed a number of times, those who noted a worsening did so about 3/4 of the time.

This was one of the first scientific attempts to correlate arthritis symptoms and the weather. Whereas the results are tantalizing, its hard, in view of the small numbers of patients studied, to draw any firm conclusions.

Arguments for there being a link

The strongest suggestion that arthritis symptoms are affected by weather is from patient surveys. About 2/3 patients in some studies state that their pain is worsened by certain weather changes. Some report how their joints help them predict the imminent arrival of wet weather, some note a dramatic improvement in their pain while on holidays in the sun (only to deteriorate on their arrival home ) and some even notice a worsening of their symptoms during heat waves. Whereas surveys are interesting, they don’t necessarily prove the link.

However, there are also some semi-plausable mechanisms as to how weather might affect joint symptoms; We know that joints  contain pressure receptors (baro-receptors) for example. Couldn’t changes in atmospheric pressure therefore be detected within joints ? The problem is that the sorts of barometric pressure changes seen with weather fluctuations are small and only of the sort of magnitude that might be experienced going up and down in a lift or on an airplane journey. It is also true that the physical properties of  tendons and cartilage can be altered by temperature changes but again, this has only been shown in laboratory experiments using extremes of temperature not usually seen in the environment . There’s even some evidence that levels of inflammatory proteins (cytokines) have been shown to decrease in patients undergoing hot spa therapy with inflammatory arthritis and of course heat (or cold) applied directly to joints also seems to help some patients too.

Some patients feel can predict weather changes in their joints

What’s surprising therefore is how prospective scientific studies over the years have failed to show a consistent relationship between various weather variables and arthritis symptoms.

This is at least partly due to the fact that these studies are difficult to do. If the weather were a new drug and researchers were trying to determine its effectiveness in the treatment of arthritis, we would be obliged to ‘blind’ both the patients AND their assessors to their weather treatment (a wet day, dry day etc). Its hard to be ‘blind’ to the weather. Unless you spend all of your time indoors – but then you are not being exposed to the weather changes (other than barometric pressure) either. People also wear clothes most of the time, which alter the humidity and temperature around joints and which could ‘blunt’ any effect that external factors might have.

Other investigators point to the difficult confounding role of psychological factors. Where someone with arthritis holds a belief, for example, that damp cold weather worsens their symptoms, they are psychologically more likely to place emphasis on information that reinforces this idea. They might be more likely therefore to remember those days where their joints were bad AND where the weather was damp and cold but not place emphasis on days where the weather was damp and cold and their joints were good. It has also been suggested that bad weather causes patients to feel depressed or to become inactive – both factors which have been shown to worsen pain.

What’s the bottom line:

Although the data is confusing, I tend to believe my patients when they tell me there joints are effected by the weather. This is true for some patients but not for all.

In my opinion, and despite and firm to data to back it up, I believe the following;

1. That arthritis is not caused by cold or damp weather. There is no evidence whatsoever that this is the case.

2. Where weather has an effect on arthritis,  it is solely on the symptoms of the disease and has no effect on disease progression or structural damage.

3. The effect of weather on arthritis symptoms varies from patient; as a rule I would have said that most patients prefer dry warm weather to cold damp weather. Patients with poorly controlled rheumatoid arthritis can occasionally flare when its very hot.

4. The better controlled a patients disease, the less they will notice fluctuations with weather changes. This is particularly true of patients with inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis).

5. Emigrating for a better life with your arthritis is probably not a good idea. If an improvement is noted on moving to another country it is quite often temporary. Uprooting yourself from the support network of your family and friends isn’t a good idea and then there’s the stress of moving to another culture, negotiating another health system etc.

6. As with all things that you can’t control its probably better not to stress about it too much. You can’t control the weather…

Sun going down on Galway bay.

Emigration and arthritis. Some things to consider.

In Arthritis and Rheumatism, rheumatoid arthritis, rheumatology, Uncategorized on January 4, 2012 at 6:50 am

One of the realities of Ireland’s fall from economic grace is the large numbers of people emigrating from our shores in search of a better life.

I know this because amongst them are some of my younger patients in my practice, many of whom are afflicted with conditions like rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Whereas many of them are doing well on treatment, and seem quite up-beat and excited to be considering the idea of a few years away, there are some downsides to consider. This is particularly true for those who are on biologic treatments for their arthritis.

Biologic therapies are a group of modern, hi tech and effective treatments for certain types of arthritis. They are also very expensive. The annual cost in this country for a patient treated with once of these drugs ranges from €15,000 to €20,000.

Although many gripe about the state of the Irish health service, one of the things it does very well is provide funding for these drugs. At present (although likely to change) there are very few restrictions on a Irish rheumatologist’s ability to prescribe biologic therapies for arthritis.

Every Irish citizen is entitled to have the costs of  subcutaneous biologics (e.g. Enbrel, humira, Simponi, Cimzia) covered (subject to shortfall)  through a fund known as the ‘HiTech scheme’.  This is usually subject to maximum shortfall per family of €132 per month and about a third of the Irish population who have a medical card (those over the age of 70yrs and those below a certain income) which entitles them to (almost) free medical care where they have to pay 50c per month per item on their prescription. The centrally funded Hi Tech scheme (which is ring fenced from other health service costs),  does not cover the costs of the Intravenous biologic drugs (e.g. Remicade, Roactemra and Orencia). These are usually funded through local hospital budget (much to the chagrin of public hospital administrators). Those with private health insurance have the costs of intravenous drugs and related infusion costs met by their insurer (a bit less than 50% of the Irish population carry health insurance).

For those patients who are considering changing jurisdiction  there are always two considerations when it comes to getting continued access to your regular arthritis medication.

1. The first is that a change in country means a change in rheumatologist. Where your new rheumatologist will effectively be the gate keeper to access treatments, your ability to get access to these drugs depends wholly on your new rheumatologist agreeing that biologic therapy is appropriate for you. Whereas consensus for patients with more severe forms of arthritis is unlikely to differ, there are often grey areas where opinions may vary. The decision making process however is more likely to be informed by local funding issues.

2.Funding for biologic therapies is much more restricted in other countries. For example, in Australia, access to biologic therapies for anklosing spondylitis is restricted to patients with a certain grade of severity of AS on Xray whereas in Ireland it is wholly at the discretion of the treating rheumatologist.

3. Even where you have Irish private health insurance, it will usually only cover you for emergency treatment abroad for a certain period.

What is the best advice for those thinking about emigrating who are on treatment?

1. Be aware that you may not automatically entitled to access to biologic treatments abroad. The HiTech scheme in Ireland only covers the cost of drugs of patients living here.

2. If you are thinking about emigrating, discuss it with your rheumatologist before making any firm decision. He/She may be able to recommend a rheumatologist and initiate contact for you.

3. Firmly establish the funding guidelines and restrictions on prescribing of these drugs in your target country and ask your rheumatologist for advice. I have included links to the UK (NICE) guidelines (for Rheumatoid arthritis Ankylosing Spondylitis Psoriatic arthritis , Australian Medicare guidelines (Rheumatoid arthritis , Ankylosing Spondylitis, Psoriatic arthritis) and Canadian guidelines. US regulations are much more complicated. I think it would be fair to say that having health insurance in the US would be imperative and that you would need to establish from the target insurer what their coverage guidelines are. Get it in writing!

If you are a patient in a country other than Ireland who has guidance you’d like to offer to foreign patients thinking of emigrating you your country, please add a comment.

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