會造成或是惡化心臟衰竭的藥物

即將出刊的Circulation. 2016;134:00–00.August 9, 2016，
AHA Scientific Statement
Drugs That May Cause or Exacerbate Heart Failure
A Scientific Statement From the American Heart Association

長長的列出一大串藥物，可以造成或是惡化心衰竭，排在最前面的就是NSAID (major)或是COX-2 inhibitors (major)，另外還有糖尿病藥，Saxagliptin/Sitagliptin (major)，還有metformin/TZD藥物等。還有患者PAOD常用的Cilostazol (major, evidence: A)，或是心律不整藥(Diltiazem/Verapamil)。

藥物副作用機轉：Drugs may cause or exacerbate HF by causing direct myocardial toxicity; by negative inotropic, lusitropic, or chronotropic effects; by exacerbating hypertension; by delivering a high sodium load; or by drug-drug interactions that limit the beneficial effects of HF medications.

洗腎患者因多重疾病，常用了許多藥物(polypharmacy)，因此這份藥物清單，可以給我們仔細看一下，患者到底用了幾種？有沒有機會可以停用？

http://circ.ahajournals.org/content/circulationaha/early/2016/07/11/CIR.0000000000000426.full.pdf

【投書】胡方翔：在華航空服員罷工現場 看醫護行使集體勞動三權困境 https://shar.es/1lhSN0 via @sharethis

看著華航空服員罷工大獲全勝，我們過勞的醫界，有同樣的機會嗎？或是可以借鏡之處？藉由胡醫師這篇投稿，可以讓我們更有全面性了解，以及比較。

以下摘取三段航空和醫療比較之處供參考，詳文可見天下網站

----------------------
【投書】胡方翔：在華航空服員罷工現場 看醫護行使集體勞動三權困境
https://shar.es/1lhSN0 via @sharethis

「獨立評論@天下讀者投書 2016/06/25

作者: 

胡方翔

1) 
醫療業空有勞動三權，最重要的平權武器──罷工或爭議權，醫護擁有的也是個「受限制」的罷工權。依勞資爭議處理法53條第1項規定，工會主張「罷工權」，必須調解先行，54條第1項規定，且須直接無記名投票經全體半數同意，54條第2項規定，下列影響大眾生命安全、國家安全或重大公共利益之事業，勞資雙方應約定必要服務條款，工會始得宣告罷工。醫療屬第三款──醫院。因醫療工會的組織穿透率極低，僅1%不到，產業工會或職業工會也不能直接參與醫院勞資會議協商，沒有充分協商權與爭議權的工會為後盾，只是無牙老虎，困在無法訂出醫療「必要服務條款」與「維持基本服務」，醫療罷工權實陷於被去勢的失能狀態，絕對不會有突襲式罷工。況且醫護皆有所謂「倫理規範」的專業拘束，就是俗稱的「醫德」條款，如此醫療是消費嗎？恐怕只會被社會集體無知所消費。

2) 
華航空服員罷工，讓人們看穿「公會非工會」，有任何醫護的公會聲援罷工嗎？台灣醫界有公會而沒工會，而且是依醫師法第9條，強制入會；公會是資方團體（表3-4），看看公會不符合勞動組合的四大要件即知：1.非強制入會；2.受雇身分，勞雇關係存在；3.組織章程明文保障會員勞動權益；4.獨立自主性，組織運作不受支配；最好還要完成法定登記程序，以取得合法工會身分。故台灣的勞方團結組織猶待努力。這次的指標性罷工，等於宣告台灣「全國醫療產業工會」即將成立，應該納入醫療法所規定的各類醫事人員，以創造最大的醫界團結。

3)
▋看看英國 台灣的路仍很漫長
英國BMA，除了是醫師協會，也是註冊工會，是官方認定的主要溝通管道。但台灣目前僅有公會，並無全國性的醫師工會，這是台英制度與觀念的差異。英國行公醫制，僱主是國家，醫師透過工會調解或罷工，協商的勞動條件單純取決於國家是否接受。台灣的情況相對複雜，除了沒有代表性工會外，多數醫師的收入大部分或全部都來自健保給付，實質僱主是健保，但醫院是法律上僱主，若醫師要抗爭，只能透過與醫院協商，間接促使主管機關面對訴求；以目前醫師無醫療勞動人權保障，要走的路仍很漫長。

（作者為腎臟醫師，管理學、法律碩士，目前就讀政大勞工所碩士班。）

The Big Business of Dialysis Care

NEJM Catalyst http://catalyst.nejm.org/the-big-business-of-dialysis-care/

June 9, 2016
Ron Shinkman
Health Care Editor and Journalist

NEJM 的Catalyst 這一期談到美國的透析治療，其中有些有趣的數字和比較，提供大家參考。

According to the U.S. Renal Data System, 468,000 patients underwent dialysis in 2013. That’s a nearly 47-fold increase in 40 years, driven in part by the rise nationwide in diabetes, hypertension, and other chronic conditions.”

拜慢性病（尤其是糖尿病患者增加之故），美國洗腎患者在40年內，增加了47倍，目前約468,000位透析患者。

在1973年，透析治療納入美國的Medicare給付項目。一開始約10,000個透析患者，當時一年花費 $200 million。

目前2015, Medicare每年花$34 billion透析費用。

透析死亡率下降 36%，between 2001 and 2013。

The Corporatization of Dialysis Delivery

美國也是有愈來愈多，私人的透析院所，在shopping mall也有。

前二大透析器材供應商占了70%，Fresenius Medical Care and Colorado-based DaVita Healthcare Partners。

這二大供應商共有3,900透析點，幾乎是以下超市的數量總合(Target, Best Buy, and Publix Super Market stores)

It currently costs about $88,000 a year for a patient to undergo dialysis, according to the USRDS. That’s about 60% more than what the average U.S. household earns in a year.”

根據USRDS，目前每位透析患者年花$88,000費用(透析+住院+急診），這數字超過一般美國家庭平均收入的60%。Fresenius的資料，美國透析患者，一季大約住院10天，(more than double the hospital days for its patients in Asia or Latin America)。(筆者註：台灣透析患者還是照顧得比美國好）

The two leading dialysis companies, German conglomerate Fresenius Medical Care and Colorado-based DaVita Healthcare Partners, control about 70% of the U.S. market.”

有non-profit 和 for-profit 經營者，non-profit的患者死亡率較低。

The big for-profit operators have also been shown to have much higher mortality rates than nonprofit dialysis centers in the U.S. A 2010 article inHealth Services Research tallied a 19% higher risk of death at Fresenius facilities, and a 24% higher death risk at DaVita facilities, than patients receiving care at the biggest nonprofit chain. 

美國的透析患者死亡率比歐洲和日本高，原因可能是：營養不良，和工作人員的訓練不足。

2009, “Why Is the Mortality of Dialysis Patients in the United States Much Higher than the Rest of the World?”  U.S. one-year mortality rates were among the highest in the world: 21.7% in 2003, versus 15.6% in Europe and 6.6% in Japan. The authors fingered patient nutrition and staff training as particular causes of the discrepancy.

Cost Growth, and Cutbacks

透析費用逐年成長，Medicare 2011年開始包裹給付，每次$240。

2011, Medicare began bundling dialysis care payments in an attempt to better control expenses, paying about $240 per treatment, or around $37,000 a year.

透析患者若是有私人保險，則一開始透析前30個月由私人保險給付，後來才由Medicare接手（私人保險給付透析的金額較高，約2倍）。

Private payers typically pay at least twice Medicare rates

Home dialysis isn’t always feasible: Patients must be able to take care of a lot of the dialyzing themselves, or have the means for a home caregiver, among other variables.”

Home dialysis可以節省透析費用支出，目前Fresenius’ and DaVita’s home dialysis rates hover around 20% and 10%, respectively. 

Empowered Dialysis

1) 教病人透析時做瑜伽，增加循環。

Richard Gibney, MD,  in Waco, Texas, Fresenius-owned dialysis centers
Yoga classes for patients as they’re being dialyzed — a response to the rising rates of diabetes among the patients and a need to increase their circulatory performance.

Gibney’s most radical approach toward dialysis is the notion of “empowering” patients by having them perform some or much of the setup and monitoring of their treatment.”

2) Gibney醫師，讓病人自己準備透析用品，設定，打針，以及自己監測透析、回應警報發生時處理，目前他有280位病人是"empowered dialysis"，和傳統由護理人員操作透析相比，這群"empower dialysis"病人，有較少的死亡率和住院率。（瑞典首創‘hunker-down dialysis.’，據說可以減少33%透析費用和增加病人滿意度）

另一家醫療公司試圖用科技來幫忙透析：Outset Medical, based in San Jose, California

Tablo這台機器，設計成讓透析就像在ATM領錢或是自行結帳的商店一樣方便，照螢幕指示，一步一步完成。

A marker of success for Tablo would be in making dialysis pleasant enough for patients to reduce missed treatments, which average more than 13 per year and lead to higher hospitalization rates.”

Tablo 會減少工資支出，減少medical complications (?)，減少病人因故沒有至院所透析的機會，和透析技術人員的工作機會?（因為病人都可以自己操作機器了）

Technician staffing are going to lose their jobs?

“I said ‘No, that’s totally wrong. We’re transitioning from you being a worker bee, a madman like you’re running cattle through a chute, to becoming teachers, mentors, and cheerleaders,’ ” he says.

筆者註：我怎麼覺得最後一段是在安慰透析從業人員的？當機器可以和病人配合把透析這件事做好，那還需要那麼多的員工嗎？時事評論一下：華航空姐這次罷工，成功得獲得所要求的權利固然可喜，然而華航高層目前會不會在想，「是不是該請鴻海郭董研發個機器人空姐了呢？」

Ron Shinkman

Los Angeles–based health care editor and journalist specializing in economics and public policy

The Big Business of Dialysis Care

NEJM Catalyst http://catalyst.nejm.org/the-big-business-of-dialysis-care/

June 9, 2016
Ron Shinkman
Health Care Editor and Journalist

NEJM 的Catalyst 這一期談到美國的透析治療，其中有些有趣的數字和比較，提供大家參考。

According to the U.S. Renal Data System, 468,000 patients underwent dialysis in 2013. That’s a nearly 47-fold increase in 40 years, driven in part by the rise nationwide in diabetes, hypertension, and other chronic conditions.”

拜慢性病（尤其是糖尿病患者增加之故），美國洗腎患者在40年內，增加了47倍，目前約468,000位透析患者。

在1973年，透析治療納入美國的Medicare給付項目。一開始約10,000個透析患者，當時一年花費 $200 million。

目前2015, Medicare每年花$34 billion透析費用。

透析死亡率下降 36%，between 2001 and 2013。

The Corporatization of Dialysis Delivery

美國也是有愈來愈多，私人的透析院所，在shopping mall也有。

前二大透析器材供應商占了70%，Fresenius Medical Care and Colorado-based DaVita Healthcare Partners。

這二大供應商共有3,900透析點，幾乎是以下超市的數量總合(Target, Best Buy, and Publix Super Market stores)

It currently costs about $88,000 a year for a patient to undergo dialysis, according to the USRDS. That’s about 60% more than what the average U.S. household earns in a year.”

根據USRDS，目前每位透析患者年花$88,000費用(透析+住院+急診），這數字超過一般美國家庭平均收入的60%。Fresenius的資料，美國透析患者，一季大約住院10天，(more than double the hospital days for its patients in Asia or Latin America)。(筆者註：台灣透析患者還是照顧得比美國好）

The two leading dialysis companies, German conglomerate Fresenius Medical Care and Colorado-based DaVita Healthcare Partners, control about 70% of the U.S. market.”

有non-profit 和 for-profit 經營者，non-profit的患者死亡率較低。

The big for-profit operators have also been shown to have much higher mortality rates than nonprofit dialysis centers in the U.S. A 2010 article inHealth Services Research tallied a 19% higher risk of death at Fresenius facilities, and a 24% higher death risk at DaVita facilities, than patients receiving care at the biggest nonprofit chain. 

美國的透析患者死亡率比歐洲和日本高，原因可能是：營養不良，和工作人員的訓練不足。

2009, “Why Is the Mortality of Dialysis Patients in the United States Much Higher than the Rest of the World?”  U.S. one-year mortality rates were among the highest in the world: 21.7% in 2003, versus 15.6% in Europe and 6.6% in Japan. The authors fingered patient nutrition and staff training as particular causes of the discrepancy.

Cost Growth, and Cutbacks

透析費用逐年成長，Medicare 2011年開始包裹給付，每次$240。

2011, Medicare began bundling dialysis care payments in an attempt to better control expenses, paying about $240 per treatment, or around $37,000 a year.

透析患者若是有私人保險，則一開始透析前30個月由私人保險給付，後來才由Medicare接手（私人保險給付透析的金額較高，約2倍）。

Private payers typically pay at least twice Medicare rates

Home dialysis isn’t always feasible: Patients must be able to take care of a lot of the dialyzing themselves, or have the means for a home caregiver, among other variables.”

Home dialysis可以節省透析費用支出，目前Fresenius’ and DaVita’s home dialysis rates hover around 20% and 10%, respectively. 

Empowered Dialysis

1) 教病人透析時做瑜伽，增加循環。

Richard Gibney, MD,  in Waco, Texas, Fresenius-owned dialysis centers
Yoga classes for patients as they’re being dialyzed — a response to the rising rates of diabetes among the patients and a need to increase their circulatory performance.

Gibney’s most radical approach toward dialysis is the notion of “empowering” patients by having them perform some or much of the setup and monitoring of their treatment.”

2) Gibney醫師，讓病人自己準備透析用品，設定，打針，以及自己監測透析、回應警報發生時處理，目前他有280位病人是"empowered dialysis"，和傳統由護理人員操作透析相比，這群"empower dialysis"病人，有較少的死亡率和住院率。（瑞典首創‘hunker-down dialysis.’，據說可以減少33%透析費用和增加病人滿意度）

另一家醫療公司試圖用科技來幫忙透析：Outset Medical, based in San Jose, California

Tablo這台機器，設計成讓透析就像在ATM領錢或是自行結帳的商店一樣方便，照螢幕指示，一步一步完成。

A marker of success for Tablo would be in making dialysis pleasant enough for patients to reduce missed treatments, which average more than 13 per year and lead to higher hospitalization rates.”

Tablo 會減少工資支出，減少medical complications (?)，減少病人因故沒有至院所透析的機會，和透析技術人員的工作機會?（因為病人都可以自己操作機器了）

Technician staffing are going to lose their jobs?

“I said ‘No, that’s totally wrong. We’re transitioning from you being a worker bee, a madman like you’re running cattle through a chute, to becoming teachers, mentors, and cheerleaders,’ ” he says.

筆者註：我怎麼覺得最後一段是在安慰透析從業人員的？當機器可以和病人配合把透析這件事做好，那還需要那麼多的員工嗎？時事評論一下：華航空姐這次罷工，成功得獲得所要求的權利固然可喜，然而華航高層目前會不會在想，「是不是該請鴻海郭董研發個機器人空姐了呢？」

Ron Shinkman

Los Angeles–based health care editor and journalist specializing in economics and public policy