Overactive bladder Is it a disease

According to the Urology Care Foundation, the official foundation of the American Urological Association, 33 million Americans suffer from overactive bladder (OAB). Thats 30% of all men and 40% of all women in the United States. The foundation estimates that the actual number is much larger because many people who have overactive bladder problems are embarrassed and do not seek care.

This represents a nearly twofold increase since 2001 when a paper written said 17 million people had the problem.

Its not clear how either of the two sources cited above obtained their information.

Maybe you didnt know that there are two kinds of OAB. "Dry" is the one where the patient is able to get to the bathroom on time. "Wet" is the form that is accompanied by leakage of urine also known as the urge incontinence.

Here is something else you probably didnt know. The disease was virtually unknown before 1997.

What happened in that year?

A drug company, Pharmacia, had a drug called Detrol that they were originally going to market for the treatment of urinary incontinence. However the number of people with urinary incontinence was small. They decided to focus on people who had urinary frequency and urgency and declared that incontinence was not absolutely necessary to make the diagnosis of OAB.

As related in the book "Our Daily Meds," the drug company had to convince people who went to the restroom frequently and were previously treated with conservative measures such as restricting fluid intake and eliminating caffeine from the diet that OAB was not just an annoyance or inconvenience but a serious condition requiring professional medical care. They named it "Overactive Bladder."

A special supplement to the journal Urology in 1997 contained 30 articles about OAB, a number of which were written by doctors who were paid by Pharmacia.

Here is a graph by year for the 4803 papers listed in PubMed on the subject of OAB since the term first appeared in 1977.

Of the 69 papers written before 1997, only 7 used the term "overactive bladder."

There are now seven drugs for the treatment of OAB on the market. Consumer Reports says that none of the seven is clearly more effective than the others. The monthly cost of these drugs can be as low as $4.00 for a generic to $300 for a brand name medication.

In 2010, the website Decision Resources predicted that "the OAB drug market will increase from approximately $3 billion in 2009 to nearly $4 billion in 2019 in the United States, France, Germany, Italy, Spain, United Kingdom and Japan."

Not a bad return for treating a disease that did not even exist until 18 years ago.

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Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

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Meaningful Use Stage 3 Is Coming Should Be Fun

An alert reader tipped me off to something many of you may not be aware of. Stage 3 of Meaningful Use is close at hand.

The "proposed" rules will be officially published on March 30. The good news is that comments will be received for a couple of months.

The bad news is that if the Office of the National Coordinator for Health Information Technology is anything like every other regulatory body Ive ever dealt with [e,g., the ACGMEs Residency Review Committee for Surgery], the "proposed" rules will be the real rules and the comments will be simply a way for disgruntled physicians to vent.

If you dont believe me about the venting, take a look at the 185 mostly negative comments posted on Medscape’s story about Stage 3.

Here are a few of the new rules that will be in effect by 2017 or sooner.

More than 25% of patients seen by an eligible professional (EP) or discharged from a hospital or emergency department (ED) must "actively engage" with their electronic health records (EHRs).

When I was practicing, I had trouble getting some patients to take their medicine or even get out of bed. I don’t know where the people making these rules live, but most of my former patients were highly unlikely to actively engage with their electronic records. I suppose as is the case with unplanned readmissions of noncompliant patients, penalties will be handed out if only 24% of one’s patients engage their records.

Patient-generated data from a nonclinical setting must be incorporated into the EHR for more than 15% of patients seen by the EP or discharged from a hospital or ED.

A “nonclinical setting” is something such as home health care or physical therapy. How anyone is going to be able to track this? Did they mandate only 15% because they know this will be nearly impossible to comply with?

EPs and hospitals must use their EHR to create a summary of care and electronically exchange it with other providers for more than 50% of transitions of care and referrals. In more than 40% of these transitions of care, the provider has to incorporate in its EHR a summary of care from an EHR used by a different provider. In more than 80% of transitions of care, the provider has to perform a "clinical information reconciliation" that includes not only medications and allergies, but also problem lists.

EHRs from different vendors lack "interoperability." They dont communicate very well with each other. “Copy and paste” is out of control now. Wait until you see what happens when people try to comply with these transition of care rules—assuming that EHRs from other doctors can even be opened. This is going to be a monumental amount of work, all of which of course will be uncompensated.

I retired more than two years ago. In social situations, I’m often asked, “Do you miss being a doctor?” I miss the satisfaction that came from helping patients and most of the people I worked with, but I don’t miss the ever-expanding bureaucracy, regulations, and busywork associated with practicing and teaching surgery.

Old age has its rewards. One of them is not having to deal with Stage 3 or even Stages 1 and 2 of Meaningful Use.

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