Journal of Humanitarian Affairs: Senior health care in rural areas may be lacking

Rural Waianae Coast where many people struggle with finances, cost of medical care and access

Carol Forsloff --It took nearly four hours to get a prescription for Tamiflu and another two hours to bring it home from Kaiser, along with a cost that included insurance support that would make it prohibitive for many elderly people on fixed incomes, which is a problem when influenza protection is particularly important for older folk. Much of the problem had to do with poor or delayed communication, which can be an issue when Kaiser and other medical facilities have strained budgets and a burgeoning population of the medically needy.

The cost of key medication, especially during flu outbreaks, and the difficulties in obtaining it can create particular problems for the elderly, and most especially the poor elderly in rural areas, such as the Waianae Coast of Oahu in Hawaii.

Kaiser prides itself on its excellent in-house communication, however in- house the communication is often lacking in some places, especially in areas that serve the poor and disadvantaged populations, like the Waianae Coast of Hawaii, as I have personally observed as a patient. It is not uncommon to call for prescription refills requiring a doctor's assent and to learn the doctor was never contacted. It is also not uncommon to have the basics unavailable that one might need on a hot day in August, when a water fountain took two months to fix. In addition the laboratory personnel and front desk folk were unable to provide any water or any recommendation where it might be found within the clinic. So a trip to a local store was required just to have sufficient water to provide a urine sample.

The cost of Tamiflu was nearly $100 for two people in the Kaiser pharmacy. That was surely a savings from the $146 per person it might have been at a local pharmacy without insurance. The problem is that Kaiser requires patients to purchase solely from its pharmacies in Hawaii; and if one conveniently becomes ill during regular business hours, the strategy may work, especially since there are clinics in various locations of Oahu and the outer islands.

But woe to those who may need medications on an evening or weekend, for they are available only at the Kaiser Moanalua Hospital location, an hour's drive from the Waianae Coast and more in some areas of Oahu. The time is increased during the late afternoon hours because of work traffic. If one is elderly and unable to drive, the problem in obtaining it is multiplied. Add to that the discomfort in making the trip when a senior is ill.

A missed appointment because of traffic congestion and accidents on Oahu during construction, now taking six hours daily at key hours, might bring the offer of a telephone appointment, as has occurred with me. However, the nurse's office recommending it, not making contact with the doctor in question meant not only no appointment or physician consult but no requested medication update sent to the pharmacy. The medication in question was one for a prolonged lung infection with complicated features that needed to be taken at key intervals.

These are matters who, for the young and the well, may not necessarily create problems, although they can. But they most certainly can cause medical errors or exacerbate distress for the elderly. And emotional distress can be an issue. It can create mistakes in both diagnosis and treatment, especially when there are existing, complex medical problems involved, as often occurs with seniors in the advanced years of aging.

These concerns are exacerbated by the fact that many of the elderly lack family members to prove transportation support and help with tracking information.

In a survey of physicians in 2010, doctors were found to remember their diagnostic errors and shared their experiences with others, in order to highlight some of the problems and reduce the potential for misdiagnoses. What the survey found is the most common missed or delayed diagnosis were the following: pulmonary embolism (4.5%), drug reactions or overdose (4.5%), lung cancer (3.9%), colorectal cancer (3.3%), acute coronary syndrome (3.1%), breast cancer (3.1%), and stroke (2.6%).

Medical errors can occur at any point during patient interaction and testing. What the survey found was they occurred more often in the testing phase (44%), followed by clinician assessment errors (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%).

In the Archives of Physician's Weekly, reports point out medical errors during the diagnostic phase to be of consequence in surveys of doctors. When doctors make a mistake, it's something they remember and want to fix most of the time.

Deaths by wrong diagnoses are between 40,000 and 80,000/year according to Bottom Line.The impact on patient care and also on the doctors themselves is significant. Studies have found doctors have increased stress when they discover mistakes, whether they are made by others or themselves. Studies have also found that most errors have to do with youth or physician fatigue. Diagnostic errors have been found to be more frequent than medication errors. But problems with communication have also been found to be paramount in providing accuracy in either diagnosis or treatment.

But one of the most serious, and frequent reasons, for misdiagnoses has to do with physician bias, according to a study reported 2010 in U.S. News and World Report. Some doctors fixate on a specific problem or issue which can override good judgment at times, the report maintains. It is complicated by clerical errors and mis-communication, as most doctors pride themselves on a positive relationship with patients.

In the case of Kaiser, physician service has been satisfactory for this patient. On the other hand lack of timely communication and coordination from the administrative side of the equation can create problems.

What might medical facilities do to improve their service to patients? It takes more than a good doctor. It takes more than brightly-lit sitting areas and smiling faces or a hospital renovation that offers a more sprightly atmosphere than the dull, gray walls they once were.

What professionals who examine the medical profession, and those services related to it, have found is the need for care in how information is provided to everyone involved with a patient in some way, including support staff.

In Oregon Kaiser is hard at work in making sure that within its newest flagship hospital on the west side of Portland and associated clinical offices, everyone from the management and top physicians to the janitor and food staff are advised on how to interact with patients and how to observe key behaviors that might elevate service in general.

In rural areas of the United States, and other areas of the world, medical care is either lacking or difficult to obtain readily, according to surveys. It is an issue in Hawaii and likely in other places that can create additional health problems for vulnerable patients that can add to the overall costs for everyone.

Accurate information and speed of service delivery, as well as availability of medications, are the issues that are critical to seniors and to children, those who are too young or infirm to find their way through a maze of misinformation and mistakes, when patient care is the central concern. It helps accuracy when those issues are addressed.

Mild stress can interfere with emotions