NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

CDC

This week, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.

First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections.

About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the infections, the CDC researchers reported in the New England Journal of Medicine.

On the bright side, those numbers are less than half the number of hospital-acquired infections that a national survey estimated in 2007. And a second report issued this week found significant decreases in several infection types that have seen the most focused prevention efforts on a national scale.

Noteworthy was a 44 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2012, as well as a 20 percent reduction in infections related to 10 surgical procedures over the same time period.

These infections were once thought to be inevitable, resulting from patients who were too old, too sick or just plain unlucky. We now know that we can put a significant dent in these events, and even achieve zero infections among the most vulnerable patients.

At Johns Hopkins, we created a program that combated CLABSI in intensive care units through a multi-pronged approach—implementing a simple checklist of evidence-based measures while changing culture and caregivers’ attitudes through an approach called the Comprehensive Unit-based Safety Program (CUSP). The success was replicated on a larger scale across 103 Michigan ICUs and then later across most U.S. states, withimpressive results.

These and similar successes have changed caregivers’ beliefs about what is possible, and inspired more efforts to reach zero infections.

What will it take to attain this goal—or at least get much closer?

Continue reading “Hospital Acquired Infections: How Do We Reach Zero?”

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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”

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Between October 1 and 17, the federal government ceased all nonessential operations because of a partisan stalemate over Obamacare. Although it is premature to declare this the greatest example of misgovernance in modern U.S. Congressional history, this impasse ranks highly.

One casualty of the showdown was any consideration of changes to lessen the impact of the across-the-board sequestration cuts that began on March 1. The cuts have caused economic and other distress across the nation, including serious impacts within the health care sector. Nearly eight months into sequestration, we can move beyond predictions and begin to quantify these effects.

Consider the following impacts of sequestration on Federal health agencies and activities:

NATIONAL INSTITUTES OF HEALTH

Cuts to the FY13 budget: $1.71 billion or 5.5%

This includes:

A 5.8% cut to the National Cancer Institute, including 6% to ongoing grants, 6.5% to cancer centers, and 8.5% to existing contracts

A 5.0% cut to National Institute of General Medical Sciences, and a 21.6% drop in new grant awards

Among the effects:

  • 703 fewer new and competing research projects
  • 1,357 fewer research grants in total
  • 750 or 7% fewer patients admitted to NIH Clinical Center
  • $3 billion in lost economic activity and 20,500 lost jobs
  • Estimated lost medical and scientific funding in California, Massachusetts, and New York alone of $180, $128, and $104 million respectively.

Dr. Randy Schekman, whose first major grant was from the National Institutes of Health in 1978, said winning this year’s Nobel Prize for Medicine made him reflect on how his original proposal might have fared in today’s depressed funding climate. “It would have been much, much more difficult to get support,” he said.  Congresswoman Zoe Lofgren (D-Calif.) noted the irony that because of sequester cuts, NIH funding was reduced for the research that resulted in Yale’s James Rothman sharing in the 2013 Nobel Prize for Medicine.

Continue reading “The Sequestration Cuts That Are Harming Health Care”

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As Washington remains deadlocked on the implementation of the Affordable Care Act, the US government’s shutdown has resulted in the furlough of nearly 70% of the Centers for Disease Control‘s (CDC’s) workforce. CDC Director Tom Frieden recently shared his thoughts in a tweet. We agree whole-heartedly.  Although it’s all too easy to take the CDC staff for granted, they are the frontline sentinels (and the gold standard) for monitoring disease outbreaks.  Their ramp-down could have serious public health consequences.

We are particularly concerned about the apparent temporary discontinuation of the CDC’s flu surveillance program, which normally provides weekly reports on flu activity. Although flu season typically begins in late fall, outbreaks have occurred earlier in previous years. In 2009, flu cases started accumulating in late summer/early fall.  And given the potential for unique variants, such as the swine or avian flu, every season is unpredictable, making the need for regular CDC flu reports essential. We therefore hope to see the CDC restored to full capacity as soon as possible.

In the meantime, we would like to help by sharing data we have on communicable diseases, starting with the flu.


Because the athenahealth database is built on a single-instance, cloud-based architecture, we have the ability to report data in real time. As we have described in earlier posts, the physicians we serve are dispersed around the country with good statistical representation across practice types and sizes.

 

To get a read on influenza vaccination rates so far this season, we looked at more than two million patients who visited a primary care provider between August 1 and September 28, 2013 (Figure 1).  We did not include data on vaccinations provided at retail clinics, schools or workplaces.

This year’s rates are trending in parallel to rates over the last four years, and slightly below those of the 2012-2013 season. However, immunizations accelerate when the CDC, and consequently the media, announce disease outbreaks and mount public awareness campaigns.

Continue reading “With CDC Seasonal Flu Data Unavailable, An Electronic Medical Record Offers a Glimpse of Early Activity Levels”

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The shutdown could not stop the rollout of the state and federal exchanges.

That’s because the Obama administration, sensing a political fight in the offing with Republicans, wisely prepaid the bill for the insurance exchanges and other key components of the rollout.

On the other hand, the fiscal standoff is having a very real impact on the infrastructure that supports healthcare across the United States.   Agencies from the Centers for Disease and Control to the National Institutes of Health have seen their money turned off. Others have seen their staffing levels sharply reduced with non-essential employees furloughed.

It doesn’t take a wild imagination to imagine potential deadly consequences if something goes wrong. If for example, flu season strikes early or a drug recall  is needed.  Much of the pain will be felt over time.  As the shutdown drags on, you can expect problems that are brewing under the surface to become much more visible …

Here’s a review of what’s happening:

Centers For Disease Control and Prevention
Funding for monitoring of disease outbreaks turned off. Lab operations sharply scaled back. 24/7 operations center to remain online.  With some scientists predicting a severe 2013-2014 flu season, this is cause for concern …

National Institutes For Health
Enrollment in new clinical trials suspended, impacting thousands of patients suffering from serious diseases. No action on grant proposals. Minimal support for ongoing protocols.

Food and Drug Administration
Food safety inspections sharply cut back. Monitoring of imports eliminated.  Oversight of production facilities curtailed, again potentially an issue with flu season on the way.The good news? Because drug approvals are funded by industry “user-fees” FDA approvals of new drugs will continue.

Centers For Medicare and Medicaid Services
Key ACA related operations intact.  The bad news for docs and patients – claims and payment processing expected to continue but with slower service than usual. With purse strings tight, this is likely to become more of a problem as shutdown drags on. In the unlikely event that a shutdown continues for more than a month, the impact on physician practices could be much more serious.

Continue reading “How the Federal Government Shutdown Is Hurting Healthcare: Agency by Agency”

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How do you tell the family members of a critically ill patient that their loved one is going to die because there are no antibiotics left to treat the patient’s infection?  In the 21st century, doctors are not supposed to have to say things like this to patients or their families.

Ever since the discovery of penicillin in 1940, patients have expected a pill or an intravenous injection to cure their infections. But our hubris as a society with respect to antibiotics has been exposed by the rise of antibiotic-resistant “superbugs.”

The Centers for Disease Control and Prevention (CDC) recently issued a new study, entitled “Antibiotic resistance threats in the United States, 2013,” reporting that at least 2 million people become infected with bacteria that are highly resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. These estimates are highly conservative.  Many more people die from other conditions that were complicated by an antibiotic-resistant infection.

Meantime, we have ever-decreasing new weapons to wage the war against such infections because the availability of new antibiotics is down by more than 90% since 1983.

Interventions are needed to encourage investment in new antibiotics, to prevent the infections in the first place, to slow the spread of resistance and to discover new ways to attack microbes without driving resistance.

A major reason for the “market failure” of antibiotics is that they are taken for short periods of time, so they have a lower return on investment than drugs that are taken for years (such as cholesterol-lowering drugs).  The Food and Drug Administration can help reverse the market failure by adopting new regulatory approaches to encourage development of critically needed new antibiotics.

Continue reading “New Interventions Needed to Halt the Growth of “Superbugs””

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The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease:  The Power to Prevent, the Call to Control.   On the summary page we learn some shocking statistics:

  • “Chronic diseases cause 7 in 10 deaths each year in the United States.”

  • “About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”

  • “More than 75% of health care costs are due to chronic conditions.”

Shocking, that is, in how misleading or even false they are.  Take the statement that “chronic diseases cause 7 in 10 deaths,” for example.  We have to die of something.   Would it be better to die of accidents?  Suicides and homicides?  Mercury poisoning?   Infectious diseases?    As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.

The second statistic is a head-scratcher.  Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally.   Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.”   Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI  > the 95th percentile, which of course is mathematically impossible.

More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one?    Are they counting back pain?   Tooth decay?  Dandruff?   Ring around the collar?    “The facts,” as the CDC calls them, are only slightly less fatuous.   For instance, the CDC counts “stroke” as a chronic disease.   While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says.  Indeed it is hard to imagine a more acute medical event.

They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition.   Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death.    “Chronic disease” implies a need for and response to ongoing therapy and vigilance.  If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.”  And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”

Continue reading “The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending”

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At my infectious-diseases clinic in Southeast Washington, I work with some of the city’s most indigent patients. Some don’t have jobs, a home, a car or enough to eat. But recently, I saw a patient whose problem made these issues seem trivial.

Dealing with fatigue, a cough and a fever for several months, this woman in her 40s had been evaluated by four internists. They had tested her for a variety of conditions but not HIV. Each had recommended rest, two prescribed antibiotics, and one suggested an over-the-counter cough medicine. Experiencing no physical relief from these suggestions, the woman had decided to “lay down and die.”

However, after her longtime partner insisted she get medical help, she agreed to go to a hospital emergency room. After a rapid test, which she initially refused because she said she was not at risk for HIV, she learned that she was HIV-positive.

After that ER visit, she brought her partner, whom she credits with saving her life, to my clinic to be tested; she was concerned that she had transmitted the virus to him. He tested positive. About a week later, when he accompanied her to an appointment with me, I asked if he had been seen by a doctor to discuss treatment. He said no and indicated that he wanted to establish care in the clinic.

When I asked if he had ever been on HIV drugs, he gazed at the medication chart and pointed out his previous regimen, a cocktail that contained indinavir. Because I and many other doctors stopped prescribing this medication a decade ago, I knew he had been keeping his condition from her for years. He stopped talking and avoided my gaze. It was clear he knew that I had learned his secret. I had many questions for him; but this visit was for her.

It was not the right moment to dredge up this history and ask how he could keep his diagnosis hidden while watching his partner struggle with her health. I chose not to ask about his dishonesty, their relationship and whether they had used condoms to protect her from getting HIV. At this point, I needed to help her understand that, even though she felt weak and sick, the medications would soon make her feel better. And that, with the right treatment, she could still live a long life.

While talking with my patient about her treatment, my mind kept wandering back to her partner’s secret. Was it my role to admonish him in front of her, or would that make things worse? What would they say to each other when they got home? I wanted to discuss these questions, but did I have a right to insert my judgment into this situation? At a private visit with me two weeks later, she let me know that this was the moment she realized he’d been keeping his diagnosis from her for years.

As a physician, I am not allowed to reveal any medical information about my patients or their circumstances without their written permission. This confidentiality is sacred. But in this case, that constraint felt inappropriate and irresponsible.

Continue reading “Should Doctors Keep Patients’ HIV Status a Secret?”

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CDC’s report, Problems Paying Medical Bills: Early Release of Estimates From the National Health Interview Survey, January 2011-June 2012, provides some encouraging news. The data show fewer Americans have trouble paying their medical bills.

Among adults between the ages of 18-64, the percentage of those in families that have problems paying medical bills decreased from 20.9 percent in the first half of 2011, to 19.7 percent in the first half of 2012. The news was also encouraging for teens and children 17 and younger living in families with problems paying medical bills. The percentage of these decreased from 23.7 percent to 21.8 percent for the same period.

While the report provides good news, far too many Americans still find it burdensome to access medical services.

This is why the Affordable Care Act was passed. The law helps Americans with their medical bills in several ways. It requires many insurers to cover certain preventive services at no out of pocket cost to patients. Because of the law, 71 million Americans are receiving expanded coverage of preventive services without co-pays or deductibles — including vaccines, blood pressure and cholesterol tests, mammograms, colonoscopies and screenings for osteoporosis.

The Affordable Care Act has also played a role in helping Americans access the health insurance they need. Since 2010, the law has allowed more than 3.1 million young people to stay on their parents’ health insurance policies until age 26.

Continue reading “Data Points: CDC Numbers Show Fewer Americans Have Trouble Paying Medical Bills”

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The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.

It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis.  None of this should be a surprise:  in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves.  So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.

Except when it doesn’t — and harms employees instead, which happens altogether too often.

Yes, you read that right.  While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.

Continue reading “Caution: Wellness Programs May Be Hazardous to Your Health”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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