There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.
Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.
A tragic story and, probably, a preventable death.
Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals. Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.
But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.
About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.
Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).
CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.
Continue reading “CDC: Together We Can Provide Safer Patient Care”
Filed Under: OP-ED, THCB
Tagged: Antibiotic resistance, CDC, Clostridium difficile infections (CDI), Hospitals, MRSA, Patient Safety, Tom Frieden
Mar 4, 2014
One thing that is known about electronic cigarettes: they’ve become a serious business in the United States.
Although e-cigarettes represent only a tiny percentage of the U.S. tobacco market, the industry is growing.
The number of people currently “vaping” has increased substantially over the last few years, with sales of nearly $2 billion in 2013.
Some analysts predict that this could grow to $10 billion by 2017 and eventually overtake sales of conventional cigarettes. It’s worth noting that the industry is maturing without much in the way of oversight or regulation.
We also know how e-cigarettes work—mechanically speaking. Using a battery-powered heating element, they convert liquid nicotine (sometimes flavored with food additives) into a vapor that users then inhale or “vape.”
This unique system delivers nicotine without the cancer-causing and other harmful elements associated with burning tobacco.
Unfortunately, that’s where a lot of the certainty ends. Currently, evidence for the safety, harmfulness, utility, and addictiveness of e-cigarettes is lacking.
The questions that research needs to answer, however, are clear as day—particularly since business is booming.
Are E-Cigarettes Bad for You?
Some of the food additives that flavor e-cigarette vapor may be dangerous when inhaled; the long-term health effects of inhaling the vapor are unknown. And of course, e-cigarettes still deliver nicotine, the main addictive ingredient in cigarettes and other tobacco products.
Nicotine from e-cigarettes could have detrimental effects on cardiovascular health and may impair breathing among those with already compromised lung functioning.
Continue reading “Where There’s Vapor, Is There Fire? We Need Evidence on E-Cigarettes”
Filed Under: OP-ED, THCB
Tagged: E-cigarettes, Joan S. Tucker, RAND Corporation, smoking cessation, Steven Martino, William G. Shadel
Mar 4, 2014
Some health plans sold through the Affordable Care Act’s (ACA) health insurance marketplaces use “narrow networks” of providers: that is, they limit the doctors and hospitals their customers can use.
Go to Doctor A or Hospital A and the plan will pay all or most of the bill. Go to Doctor B or Hospital B, and you may have to pay all or most of the bill yourself.
The narrow network strategy emerged long before the ACA, during the managed care era in the 1990s, and insurance companies and large, self-insured employers have used narrow networks ever since to control health care costs.
In fact, for the first time, the ACA creates new consumer protections requiring that insurers provide a minimum level of access to local providers. A number of states have exceeded these federal standards using their discretion under the new law.
Nevertheless, some consumer advocates and ACA critics still find narrow networks objectionable. Narrow networks mean that some newly insured people are no longer covered for visits to previous providers, or, if they didn’t have a doctor before, are limited in their new choices. Not infrequently, narrow networks exclude the most expensive doctors and hospitals in a community, including some specialists and academic health centers.
More expensive doctors and hospitals are not necessarily better, but for patients with a rare or complex health problem, such restrictions can be problematic.
Welcome to the world of competition in health care, because that is what narrow networks are about. Narrow networks are used by competing plans to control health care costs, and perhaps improve quality as well. In fact, if you don’t like narrow networks, you’re saying, in effect, that you don’t like competitive solutions—as least under current market conditions—to our health system’s problems.
Continue reading “Reflecting on Health Reform–Narrow Networks: Boon or Bane?”
Filed Under: OP-ED, THCB
Tagged: Commonwealth Fund, Competition, Costs, David Blumenthal, Health Plans, narrow networks, The ACA
Feb 25, 2014
Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.” There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand. That is no longer true.
Now we have published data on many vitamins and we can say that for most people they do not work. More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.
For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much. Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.
When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.
To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”
Bill’s response, he lack of trust in my advice, disturbs me at several levels. He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.
Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.
More importantly, there is increasing data that people taking a multivitamin may become less healthy.
Continue reading “That Vitamin There Could Kill You”
Filed Under: OP-ED, THCB
Tagged: alternative medicine, Cancer, doctor/ patient relationship, James Salwitz, multivitamins, practice of medicine, Wellness
Feb 25, 2014
One of the most critical issues facing our healthcare system is the fact that the IT systems we’ve put in place have not yet led to a more connected, intelligent approach to patient care.
While we have made notable headway toward interoperability through health information exchange solutions, we must dramatically accelerate our progress to support the transition to value-based care and realize our full potential as an industry.
With this vision in mind, McKesson, Cerner and other leading healthcare IT companies announced the CommonWell Health Alliance last year at HIMSS13. Members of the Alliance are united by a shared commitment to develop a core set of interoperability services and standards that will enable patient data to be shared securely across care settings and electronic health record (EHR) platforms.
In the twelve months since, tremendous progress has been made in making this aspiration a reality. CommonWell is running robust initial projects and collaborating with a myriad of practices. We’re also continuing to expand with new members who share our ideal of the trusted exchange of patient data, regardless of vendor, system, or setting.
Now, the Alliance is welcoming its first pharmacy member in CVS Caremark. This is a watershed event for several reasons.
CVS Caremark is one of the nation’s largest retail pharmacy chains and pharmacy benefit management companies. Few organizations in any segment of healthcare have more access to patient data and more trusted influence.
But CVS Caremark’s role in driving innovation in our healthcare system, and its importance to the goal of interoperability, is vital for other reasons.
Continue reading “CVS Caremark Enters CommonWell”
Filed Under: OP-ED, THCB
Tagged: CommonWell Health Alliance, CVS Caremark, HIMSS 2014, HIT, Interoperability, John Hammergren, McKesson
Feb 24, 2014
To the two certainties of life, death and taxes, add another two: mammograms and controversy surrounding mammograms.
The Canadian National Breast Screening Study (CNBSS) has reported results of its long term follow-up in the BMJ: no survival benefit of screening mammograms.
To paraphrase Yogi Berra “it’s mammography all over again.”
Is the science settled then?
Before I wade further it’s important to understand what is implied by “settling the science.”
Einstein said “no amount of experimentation can prove me right; a single experiment can prove me wrong.”In physical sciences a theory need only be disproven once for it to be cast aside. Heliocentricity cannot coexist with Ptolemy’s universe. The statement “all swans are white” is disproven by a single black swan.
What do we do with the studies that showed survival benefit of screening mammograms? Why does the CNBSS not close the debate over mammograms, like Galileo did with celestial egocentricity?
The simple and simplistic answer is because there are powerful advocacy groups, special interests; the pink-industrial complex who have a vested interest in undermining the science.
But that lends to conspiratorial thinking. Special interests cannot undermine Maxwell’s equations or Faraday’s laws just because they do not like them.
The testability of Maxwell’s equations is inherently different from verifying that screening mammograms increase life expectancy. We must acknowledge two types of science; the former, physical science, a hard science; the latter, a hybrid of biology and epidemiology, soft science.
Soft science is a misnomer. There is nothing soft about performing a randomized controlled trial (RCT), the methodological gold standard; in ensuring factors that falsely augment or attenuate impact of screening mammograms are evenly distributed, data reliably collected, cause of death accurately recorded and correctly inferred. But the human factor and all its inevitable foibles are unavoidable in soft sciences.
Continue reading “In Defense of the Defense of Mammograms”
Filed Under: OP-ED, Physicians, THCB
Tagged: Breast cancer, Canadian National Breast Screening Study (CNBSS), Cancer Screening, Daniel Kopans, mammograms, randomized controlled trials (RCTs), Saurabh Jha, USPSTF
Feb 18, 2014
Fifty years ago, President Lyndon Johnson signed designated February as American Heart Month to acknowledge and combat the “staggering physical and economic loss to the nation” caused by cardiovascular disease.
Unfortunately, that proclamation is proving to be a timeless document.
Even with broad awareness of heart disease, expansive research and a number of clinical and public health efforts to prevent, diagnose and treat cardiovascular conditions, it remains the leading cause of death in the nation. About 600,000 people die from heart disease in the United States each year—making it responsible for one out of every four American deaths.
As a research institute dedicated to helping patients and those who care for them make better informed decisions that lead to better outcomes, the Patient-Centered Outcomes Research Institute (PCORI) is acutely interested in producing new information that supports more effective cardiovascular care. The directive in our establishing legislation to consider “disease incidence, prevalence, and burden” when prioritizing research funding is a clear call for studies of cardiovascular conditions.
I’m proud to say that PCORI has answered that call. Cardiovascular disease, including heart disease and stroke, is the most commonly studied topic in our research portfolio. It is addressed in several dozen of the 192 primary research studies that PCORI has funded to date, including projects that conduct a comparative assessment of heart disease interventions, as well as those that test the effectiveness of decision support tools. Communicating information and providing tools to patients in ways that motivate them to make healthy choices is often a major challenge for clinicians.
Our comprehensive approach funds research that addresses the gaps in both information and communication that are responsible for poor outcomes in cardiovascular care.
Continue reading “Focusing on High-Impact Comparative Studies: Cardiovascular Disease in the Spotlight”
Filed Under: OP-ED, THCB
Tagged: Baylor College of Medicine, Brigham and Women's Hospital, PCORI
Feb 8, 2014
Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.
These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.
1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.
2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.
3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.
Continue reading “Is There Really a Physician Shortage?”
Filed Under: OP-ED, Physicians, THCB
Tagged: AAMC, David Auerbach, Physician Shortage, Physicians, Rand
Feb 5, 2014
Here’s a point most of us can agree on. Tackling ballooning health care costs requires more than insurance reform because the charge and cost structure for health services in the U.S. is inconsistent and irrational. The same quality CT scan that costs $500 at one outpatient facility costs $2,000 at a nearby teaching hospital.
Obamacare’s typical high-deductible insurance plans encourage many cost-conscious consumers to shop around for low-ticket items below their deductible — and that is good. However, the bulk of health care spending is attributable to patients who rapidly blow through their deductible, after which they have no incentive to shop for value. Those 5 percent of people — who spend a whopping 50 percent of the nation’s health care dollars — have little incentive to consider price. With the cost of multiple medications, frequent doctors visits, use of specialists and one or more hospitalizations a year, these 5 percent will exceed even the highest deductible in the first few months of each year.
So what might be the single most powerful tool to slow the seemingly intractable yet unsustainable increases in health spending affecting practically every family in America? “Referenced-based” pricing for health services encourages patients — most significantly, those with the highest costs — to act as smart consumers by seeking the most cost-effective care, even after they have exceeded their deductible.
Here’s how it works. Insurance companies or employers set a limit they are willing to pay for a specified service of excellent quality — say, $1,000 for a CT scan — and communicate that reference price clearly to consumers. If patients choose a location where the charge is below the maximum set reimbursement rate, they pay nothing. If they choose a provider where the charge is higher, they pay the difference.
As patient-consumers shop around for the best price and quality services, competition in the market pushes prices down and value up.
Continue reading “Prices Drop When Health Consumers Shop Around For Healthcare”
Filed Under: Economics, OP-ED
Tagged: Costs, Obamacare, Reference-based pricing, The ACA, William Frist
Jan 25, 2014
In a previous blog we demonstrated how guidelines can compromise the care of individual patients when designed to serve the health care system.
Why should treating physicians defer to guideline committees at all, we asked? For decades medical students have been taught to read and understand information from published papers.
We are all trained in critical appraisal and can keep up with the clinically meaningful literature, the literature that is relevant and accurate enough to present to patients. Just because there are nearly 20,000 biomedical journals does not mean that any, let alone all are replete with meaningful information. We can discern the valuable from the not valuable; why do we need others to tell us?
In fact, we even argued in our last post that patients can and should judge the value of medical information. After all, they face the consequences of misinterpreting the likelihoods of benefit and of harm associated with various options for care.
No one remembers the numbers that describe the chances for benefit and harm or ask more questions about the veracity of information than a patient who must choose. The smartest information managers we have ever encountered are our patients; when informed, they quickly determine the validity of the information and apply their personal values to the estimations of the chances for benefit and harm.
Take the example of a patient who recently entered into a therapeutic dialogue with one of us, RAM. This was not the traditional clinical interview. This patient had been diagnosed with prostate cancer and was scheduled for an approach to treatment that the diagnosing physician had offered as the most sensible. However, the decision did not rest easily.
The appointment with RAM was scheduled because the patient sought a dialogue that might offer a chance to reflect on the rationale for the approach he was about to initiate. Two hours into the dialogue, the patient, a 40ish year old African-American man accompanied by his wife, were mulling over the marginal benefits and harms of the options for treating an early stage prostate cancer.
The wife asked how many African-Americans were in the study under discussion. “None”. The husband perked up and then asked, “How many people in the study was my age?” “None”. They then asked if the difference in benefit was a certain, fixed amount? “No, it varies over this range.” – examining the descriptive statistics.
They then asked when the study was started and did it pertain to the present day. “It started over 15 years ago” and the stage of disease of the men in the study was generally more aggressive than in this particular case.
Continue reading “Fee for Service vs. Fee for Serving”
Filed Under: OP-ED, THCB
Tagged: Costs, doctor/ patient relationship, Fee-for-service, Nortin Hadler, Physicians, practice of medicine, Robert McNutt
Jan 15, 2014