Month: December 2007

Pilots Use Checklists. Doctors Don’t. Why Not? By Maggie Mahar

Dec 29, 2007• 21

Frequent THCB contributor Maggie Mahar returns today with another of her no-holds barred pieces on the practice of medicine, examining the the controversey over checklists for doctors. Many physicians are opposed to the idea on general principles, arguing that checklists "dumb down" medicine and remove the "art" from their craft. Outside observers disagree, noting that there is room in medicine for an approach that has helped make airline travel safe and improved efficiency in countless industries. If you enjoy this piece, you’ll find a wonderful collection of similar pieces tackling the inner workings of the healthcare system over at HealthBeat, Maggie’s blog at the Century Foundation.

Pilots Use Checklists. Doctors Don’t. Why Not?This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist”is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long”but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. "She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.”By then“she has a body temperature of 68 degrees—and no pulse.”A helicopter takes her to a near-by hospital. There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. "Her right leg and left arm [are] partially paralyzed. Her speech [is] thick and slurry. But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.”

Look at How Safe [Fill in the Blank] Is by Bob Wachter

Dec 29, 2007• 2

But is it as simple as that really? Perhaps not. In the commentary that follows, Bob Wachter has a very different take on the airline analogy. Analogies are useful things, true, he argues. But perhaps not as useful as the cure-healthcare-by-adopting-model-posed-by- [ insert industry / EU member state here ] might have us believe. Who should you believe? That’s up to you. You’ll find more of Bob’s excellent commentary on quality and patient safety in the THCB archives and on his blog, Wachter’s World.

The rate of fatal domestic airline crashes has fallen by 65% in the past decade – from an amazingly low rate of one fatal accident in about 2 million departures in 1997, to a breathtakingly low rate of one in 4.5 million departures this year. Flying just keeps getting safer and safer.

Beginning with the 1999 Institute of Medicine report on medical errors, aviation has become the poster child for patient safety. In fact, it was an aviation analogy – the translation of the 44,000-98,000 deaths per year from medical errors into “the equivalent of a jumbo jet a day crashing” – that jumpstarted the patient safety field in the first place.

On the whole, I like the aviation analogy, because it energizes us and helps illustrate the need for certain safety-oriented practices, such as standardization, simplification, simulation, teamwork training, and effective reporting systems and regulations. It is also uniquely accessible: who would ever fly electively if a big plane went down every day in the U.S.? Yet hundreds of thousands of people check into hospitals and clinics electively daily.

But lately, I’ve sensed gathering pushback against the aviation analogy – as well as against analogies from other industries. “This has nothing to do with us,” I hear from colleagues sometimes. “Healthcare is so different.” And they’re partly right. For example, we have learned that dampening down authority gradients on a med-surg ward is orders of magnitude harder than doing so in a cockpit. Here’s why: to prevent another Tenerife disaster (the horrific 1977 runway incursion/collision of two 747s, ostensibly caused when the flight engineer – who suspected there was a large airplane blocking the way – felt uncomfortable speaking up to his boss, the pilot), aviation had to transform its culture.

BLOGS: Out Lindsaying Lohan

Dec 28, 2007

And in your Friday irrelevancy….

I love those “Top 10 most emailed or read” lists and I’m hoping that Typepad will one day let me get one on THCB. Until today the most ever I saw was 3 of the top 10 in the LA Times being on Lindsay Lohan when she crashed her car into a rehab facility (or something like that).

But what beats Lindsey? It’s When Animals Attack

Tigrrr

This is a screenshot from the most read articles on the SF Chronicle’s web site. Tatiana the man-eating tiger is the top two and four of the top seven!

Bhutto’s death can only make 5^th place…

California not really uber alles

Dec 26, 2007• 9

Late last week Brian Klepper stirred things up around here calling California’s health care bill Business As Usual. Over at Spot-on earlier this week I was a little more simplistic. I call the California approach The Last of the Old Solutions, largely because it keeps intact the employer-based health insurance system and doesnt include an effective individual mandate because that needs a real tax increase. (My original title of "California not really uber alles”was somehow vetoed over there—but here I’m in charge!)

As I say over there

If the goal is universal coverage, the pay-or-play system in which employers have to offer coverage sounds good – as well as familiar – but it doesn’t really get us there. Hawaii passed something similar in the 1970s and several other states have tried some variant and still no one’s really got close to universal coverage.

Please go there and read the rest and come back here to comment if you’re feeling bored at the end of the year!

Health 2.0 San Diego Spring Fling Agenda

Dec 24, 2007• 1

So for Christmas we’re announcing our first cut of the agenda for our next Health 2.0 conference, to be held at the Westin San Diego on March 3rd-4th. Health 2.0 User-Generated Healthcare in San Francisco sold out a month before the event, so if you are planning on attending you may want to act now to reserve your spot. Early bird registration is now over, but a limited number of spots remain available. To register, visit http://www.health2con.com . For updates on Health 2.0 related news sign up for THCB UPDATE and be sure to check out the Health 2.0 blog. We hope to see you there!

My Nomination For Health Care Quote of the Year – Brian Klepper

Dec 22, 2007• 6

I was reading through other peoples’ blog posts yesterday when amazingly enough, I was here on THCB and came across this straightforward statement by Paul Levy, the CEO of Beth Israel Deaconess Medical Center in Boston.

Of course, many readers are aware that Paul has made news by establishing a blog called Running a Hospital. I think he’s probably taken some good-natured ribbing by his more straightlaced colleagues. But I admire that fact that he’s broken the bounds of decorum and speaks openly about the many tremendously difficult issues that face hospital executives.

Tiny Tim Health Care By Michael L. Millenson

Dec 21, 2007• 4

Dickens3 Every year at this time, millions of Americans turn their attention to a much-beloved story about health
care reform. I refer, of course, to Charles Dickens’ A Christmas Carol.

While this is not the traditional plot summary, it aptly describes a story rooted in the plight of a crippled young boy whose father cannot afford the care his son desperately needs. The prospect of Tiny Tim’s eminently preventable death finally breaks through Ebenezer Scrooge’s bitterness, causing the old miser to abandon his hard-hearted ways. Alas, we Americans still seem inclined to treat the demand for universal health coverage like the Scrooge of old. His dismissive cry, “Are there no poorhouses?” is echoed by our smug assertions that those in dire medical need can “just go to an emergency room.”

Would-be reformers have responded with statistics about 18,000 preventable deaths each year and stories about the real-life Tiny Tims in our midst — to no avail. A new report from the American Cancer Society concluding that those without health insurance are 1.6 times more likely to die of their disease than those with private insurance came just a few days before Christmas and a few days after President Bush’s latest veto of the State Children’s Health Insurance Program, which would help millions of children living in near-poverty.

So this holiday season, rather than tugging on heartstrings, I’d like to take the opposite approach. Forget about the waifs: let’s talk about your wallet. The Cratchit families of this country are costing you and me money.

Business As Usual: California’s Reform Proposal – Brian Klepper

Dec 21, 2007• 18

Brian_klepper In the world of health reform wonks – the writers on this blog qualify in spades – all eyes
are on California at
the moment. His Republicanism notwithstanding,
Governor Schwartzenegger has developed a generous $14 billion bill that
would extend universal coverage to all Californians by 2010.

Now
that the plan is set, the special interests are lining up. Most of the
health care groups – the physicians, hospitals, the health plans (with
the interesting exception of Wellpoint) – are supportive, fully aware
that if more money can be found for health care, they’ll be the
recipients. Also in the mix are two prominent unions: SEIU (the Service
Workers’ International Union) and the American Federation of State,
County and Municipal Employees. They are both key supporters, each with
health care workers who would benefit from the deal.

Seeking Sustainable RHIO Forest; View Obscured by Non-profit Trees by Martin Jensen

Dec 21, 2007

Martin_jensen Health Affairs just published a study by a team of Harvard
researchers that has cast a pall on the
sustainability of Regional
Health Information Organizations (also referred to as Health
Information Exchanges). The report, The State Of Regional Health Information Organizations: Current Activities And Financing,
by Julia Adler-Milstein, Andrew P. McAfee, David W. Bates, and Ashish
K. Jha, seems to imply that the maladies suffered by RHIO efforts
around the country might be fatal, at least if you read the many news stories and blogs
that are talking about it. I say "seems to" because our analysis
suggests that the industry echosphere is still missing quite a bit of
the big picture. Let’s take this step by step, starting with the
Harvard study and moving into the invisible economy and the nature of
the RHIO challenge.

First, the "scary facts" presented by the researchers:

25% of previously-listed RHIOs seem to be "defunct"
Only 20% of the remainder reported exchanging significant volumes of clinical data
Most of the data they were exchanging falls into the categories of lab results, inpatient data and medication history
A majority reported receiving in-kind donations, about half
reported grants or financial contributions and slightly less than half
reported no financial contributions

Read the rest at the Health 2.0 Blog

Say it Ain’t So, Joe by Paul Levy

Dec 20, 2007• 1

I heard a great presentation this morning by Joe Newhouse,
from the Department of Health Policy and Management at Harvard Medical
School. There was one point that he made that really caught my
attention. It was a cite to a 2004 article in the Journal of the American Medical Association
(Dimick, et al, JAMA 2004; 292: 849) that presented the issue of how
many cases you would need to collect of a certain clinical procedure to
be able to make a determination that a given hospital’s mortality for
that procedure was twice the national average. It turns out that only
for CABGs (coronary artery bypass grafts) are there enough cases
performed to have statistical confidence that a hospital has that poor
a record compared to the national average. For other procedures (hip
replacements, abdominal aortic aneurysm repairs, pediatric heart
surgery, and the like) there are just not enough cases done to make
this assessment. (By the way, if you just want to know if a hospital is
say, 20%, worse on relative mortality, you need even a bigger sample
size.)