Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.
“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.
“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.
Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.
Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.
If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.
So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.
Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.
The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.
Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.
So I asked the cardiologist if such an invasive approach was really necessary.
Continue reading “Actually, High-Tech Imaging Can Be High-Value Medicine”
Filed Under: Tech, THCB
Tagged: angiograms, Costs, CTA, FutureMed, Imaging, Interventional cardiology, Karan Chhabra, MRI, Quality
Mar 6, 2014
Hospitals are busily merging with other hospitals and buying up groups of doctors. They claim that size brings efficiency and the opportunity to deliver more “value-based” care — and fewer unnecessary services.
They argue that they have to get bigger to cut waste. What’s the evidence that bigger hospitals offer better value? Not a lot.
If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.
The Dartmouth Atlas of Health Care and other sources have shown time and again that some of the biggest and best-known U.S. hospitals are no less guilty of subjecting patients to useless tests and marginal treatments.
Larger hospitals are also very good at raising prices. In 2010, an analysis for the Massachusetts attorney general found no correlation between price and quality of care.
A study published recently in Health Affairs offered similar results for the rest of the country: On average, higher-priced hospitals are bigger, but offer no better quality of care.
Continue reading “Bigger Hospitals Mean Bigger Hospitals with Higher Prices. Not Better Care.”
Filed Under: Economics, THCB
Tagged: Costs, Hospital Mergers, Hospitals, Lown Institute, Physicians, Quality, Shannon Brownlee, value-based care, Vikas Saini
Feb 20, 2014
I recently had the privilege of becoming a Google Glass Explorer. Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.
The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web. As cool as this the technology is – is there any utility in the healthcare setting?
There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of Glass in University of California, Irvine. Applications for nursing are being developed as well. Yet will this truly impact quality? I am not sure.
Yet one thing that intrigues me about the Glass is the perspective given when using the video function. I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.
I felt like an NFL Coach reviewing game tape. For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?
According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country. Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies. So how is this common procedure taught?
The classic “watch one, do one, teach one” methodology has been modified over the years. Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending. Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own. Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?
Continue reading “Google Glass: A Paradigm Shift in Assessing Procedure Competency?”
Filed Under: Tech
Tagged: David Stein, Google Glass, Maintenance of Certification, Patient Safety, PBETs, Quality, Surgery, Tech
Feb 5, 2014
Hospitals need to overhaul their processes so they can help the un- and under-insured stay healthy.
Many people running health care institutions tell me that they have been fighting the fight, learning to be nimble, transforming their cultures, making big changes as the landscape rearranges itself like a really bad day along the San Andreas Fault.
But in comparison with the actual scale of the problems, most of the business models and strategies in health care have been sleeping like overfed dogs. It’s wake-up time in America.
Nowhere is the problem defined more clearly than in this question: How can we deal with the tens of millions of new Medicaid recipients, the tens of millions of still-uninsured poor, and the increasing numbers of the underinsured?
Today’s hospital executives formed their careers around the “volume” question: “How do we get more and better-paying customers into and through our system?”
This is a different era. Most markets do not have enough medical care to go around, between an aging population, expanded Medicaid in 25 states, and expanded numbers of insured in all states.
When there is not enough of what you are selling to go around, operating inefficiently leads to choking on volume. In order to survive under any business model we must get the volume down and the value up.
First: What can we expect in the coming years?
The Future of Medicaid, the Uninsured and the Underinsured
Medicaid numbers are astonishing if you are not used to them. Even before the projected expansion, at some time during an average year about 72 million people, close to a quarter of all Americans, are on Medicaid. At any given moment, it’s over 50 million. Medicaid is an open-ended program:
When more people are eligible, or sick, or have more complex diseases, the states and the federal government pay more.
Continue reading “What About the Poor?”
Filed Under: THCB
Tagged: Costs, health care access, Hospitals, Medicaid Expansion, Quality, the uninsured
Jan 28, 2014
In my previous blog, I made the argument that whatever strategy we use to improve care in hospitals will not be implemented and executed well without proper focus by hospital leadership. So, it is in this context, that we recently published some pretty disappointing findings that are worth reflecting on.
We examined the pay of CEOs across U.S. hospitals and found that some CEOs got paid a lot more than others. This was not surprising. CEOs of larger, urban, teaching hospitals get paid a lot more than CEOs of small, rural, non-teaching institutions. But the disappointment was around quality: we found no relationship between a hospital’s quality performance and the pay of the CEO. Holding size, teaching, and other factors constant, what was the pay of CEOs of hospitals with high mortality rates?
About the same as CEOs of hospitals with low mortality rates. What about other quality measures? Most of them didn’t really seem to matter, with the exception of patient experience, which correlated nicely with CEO compensation. It seems that when setting CEO compensation, patient outcomes are not a big part of the discussion. How could this be, and why does it matter?
How you set incentives for senior managers says a lot about your priorities. Boards generally set the salary for their CEOs and they clearly reward patient satisfaction scores. That’s good. They also seem to reward the things that build hospital reputations: having the latest technology such as a PET scanner or academic status. But are boards rewarding CEOs based on mortality rates or adherence to basic quality metrics? Not so much. Why not? I’ve spoken to a lot of board chairpersons over the years and the answer is not that they don’t care. Most boards want to reward quality and believe that they do.
The problem is that most board members lack sufficient expertise on quality metrics and can’t decipher, from the large number of quality metrics, which ones are important (like mortality rates) and which ones are not. Hamstrung, they focus on satisfaction but also end up rewarding things that feel like proxies for quality, such as having the latest technology. And here’s the part that’s frustrating – our national efforts on quality measurement and improvement are not helping. We seem to have done very little to prioritize what’s really important, and shine a light on them.
So what do we do to move forward? Some states have started requiring that boards undergo training in quality. Medicare, as a condition of participation, could certainly require that boards (or at least some members thereof) show a degree of expertise with quality. I like these ideas but worry that training programs would themselves be of variable quality, and for some boards it would become an onerous requirement without achieving real gains in expertise.
Of course, if we really want to help boards be more effective and engage healthcare leaders, the biggest thing that we could do is actually reward hospitals, in a meaningful way, based on quality. Yes, we have the value-based purchasing program, and it is well-intentioned. But, as I’ve written before, it has several big problems. First and foremost: the incentives are very weak and there is little reason to believe it will have a meaningful impact on patient outcomes. Second, the measures are diffuse – we have too many of them, some of which matter (mortality) and many which don’t in the absence of the appropriate clinical context (checking the ejection fraction on a heart failure patient). It’s hard for hospital boards to really get a clear signal on what matters if they aren’t seeing it clearly and consistently from national leaders on quality.
Continue reading “Hospital Exec Pay: If P4P is Good Enough for Doctors, Why Not the CEO?”
Filed Under: THCB
Tagged: Ashish Jha, Hospitals, Quality
Nov 8, 2013
I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.
He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening. He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs. After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.
That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath: he had a large saddle pulmonary embolus. He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care. He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality. Even after discharge, he received two nursing visits at home to ensure he was doing OK. In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed. Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.
This is the story we all hope for. And when I heard it, I have to say that I wasn’t surprised. There’s something about the BIDMC that’s unusual. Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted mortality rates for all three reported conditions: heart attack, congestive heart failure, and pneumonia. And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.
If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.
So what’s so special about them? What do they do that’s different? I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest. And in a word, it’s leadership. BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care. That commitment translates into real activities that make a big difference. Let me divert us with a story of what this might actually mean.
A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare. As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation. One call is particularly memorable. Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?”
The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better. When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.
Continue reading “How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals”
Filed Under: Tech, THCB
Tagged: Ashish Jha, BIDMC, Hospital Compare, Quality, VA Health System
Nov 6, 2013
The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.
But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.
Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?
Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.
But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.
In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.
Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).
On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.
Continue reading “In Medicine, More May Not Be Better”
Filed Under: Physicians
Tagged: Haider Javed Warraich, Outcomes, Overtreatment, Patients, Physicians, practice of medicine, Quality
Oct 23, 2013
A year and a half ago, my husband, James Morgan, and I moved back to the U.S. after living 10 years in France.
We returned more or less kicking and screaming. We had been away long enough to lose some of our American culture and to prefer the European way of life, despite our squabbles with it–and every American abroad has some squabbles. I had discovered I was a born expat, something I’d suspected my entire adult life — from my first trip to Europe when I was 19 years old–but hadn’t arranged to test until my younger daughter graduated from high school. Jim and I are both writers, and I’d thought of a book idea for him (Chasing Matisse) that would take us to France, and my intention was for us to stay there.
But there were things we’d left undone for the 10 years we’d been away that needing tending to — life was calling us back. And if the truth be known, I felt France was falling behind in the world, and her inability to change was grating. Paris was stuck in her perpetual stupendous, effervescent beauty, while nothing new happened there at all. This city I love more than any other had long since lost the artistic dynamism that had propelled it forward with Picasso, Matisse, and the other artists that the Lost Generation had adopted and promoted in the early part of the 20th century, when Malcolm Cowley wrote his classic Exile’s Return.
The World Wars had crippled France for a time, and she had gotten back on her feet. But what the French do so very well is the past — not the present or future — and this is even truer in our digital global society. The French refusal to change defines the Gallic nation in every way imaginable, and the centuries-long celebration of their grand culture is what we love about them — and is also placing them in the rear of the international pack.
Except for this — their Number One in the World (as determined by the World Health Organization) health care system.
One of the things I most dreaded about returning to America was having to deal with a health care system that was an embarrassing national wreck.
Continue reading “My Return to American Health Care”
Filed Under: OP-ED, THCB
Tagged: Beth Arnold, insurance coverage, Quality, The ACA
Oct 10, 2013
Why readmission penalties are controversial
Penalizing hospitals for high readmission rates has been pretty controversial. Critics of the program have argued that readmissions have little to do with what happens while the patient is in the hospital and are driven primarily by how sick or how poor the patient is. Advocates of the readmissions program increasingly acknowledge that while readmissions may not reflect the quality of care that occurred within the hospital, someone should be accountable for what happens to patients after discharge, and hospitals are the logical choice. While the controversy continues, there is little doubt that the metric is here to stay. This October, the CMS Hospital Readmissions Reduction Program (HRRP) will increase its penalty on excess readmissions from 1% to 2% of total hospital reimbursement.
So far, CMS has focused on readmissions that occur after patients are discharged with one of three medical conditions—acute myocardial infarction, pneumonia, and congestive heart failure. The data on the impact of the program are mixed: while readmission rates appear to be dropping, the penalties seem to be targeted towards hospitals that care for some of the sickest patients (academic medical centers), poorest patients (safety-net hospitals) and for heart failure, some of the best hospitals (those with the lowest mortality rates). No wonder the program has been controversial.
Why surgery may be different
In 2015, CMS extends the program to focus on surgical conditions, which provides an opportunity to think again about what readmissions measure, and what it might take to reduce preventable ones. And if you think about it, surgery may be different. Most patients who are admitted for Acute MI, CHF, and pneumonia are chronically ill and bounce in and out of the hospital, with any one hospitalization likely just an exacerbation of underlying chronic illness (especially true for pneumonia and heart failure). Not so for surgery—at least not for the major surgeries.
Continue reading “Finally Some Good News on Readmission Rates”
Filed Under: OP-ED, THCB
Tagged: Ashish Jha, CMS, Hospitals, Quality, Readmissions, Thomas Tsai
Sep 19, 2013
Huge numbers of older persons transition from hospitals to the nursing home. Often, an older hospitalized patient needs skilled nursing care before they are ready to return home. In other cases, a nursing home patient who needed hospitalization is returning to the nursing home. Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.
But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous. The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.
The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities. These nurses noted that very difficult transitions were the norm. Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.
Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital. They lacked essential details about their patient’s clinical status. The problem was not the lack of paper work that accompanied the patient. In fact, nurses often received reams of paper work, often over 80 pages. The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.
Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.
Continue reading “An “F” for Quality”
Filed Under: THCB
Tagged: elder care, Geriatrics, Hospitals, Journal of American Geriatrics Society, Ken Covinsky, Nurses, Nursing Homes, Outcomes, Quality, skilled nursing facilities
Aug 27, 2013