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Month: April 2013

The Global Cardiovascular Risk Score: A New Performance Measure for Prevention

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By David M. Eddy, MD

Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.

This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.

To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.

While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.

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So Who Gets Hurt By the Sequester?

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By John Wasik

The dreaded sequester cuts mandated by the Budget Control Act of 2011 went into effect this month, putting into place a 2 percent cut in Medicare spending.

While Congress can still enact a “fix” that will delay or amend these cuts, that seems unlikely as of this writing. Yet how the cuts will impact Medicare and its nearly 50 million beneficiaries is a still a moving target.

In a joint study issued September 2012 by the American Hospital Association, the American Medical Association and the American Nurses Association, it was estimated that some 766,000 jobs would be lost by 2021 if the sequester cuts went into effect.

According to the study, “Researchers forecast that more than 496,000 jobs will be lost during the first year of sequestration, and these cuts will impact health-care sectors in every state. In California alone, the health sector could lose more than 78,000 jobs by 2021.”

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Chronic Care at Walgreens? Why (Not)?

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By Ishani Ganguli, MD

Walgreens, the country’s largest drugstore chain, announced on April 4th that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).

Two Contrasting Approaches to Health Care’s API Revolution

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By Andy Oram

It’s heavy tech time at THCB. Health 2.0 is running a developer conference called Health:Refactored on May 13-4, and a big topic there will be the opening of APIs from Microsoft, Intel, Walgreens, NY Health Information Network, MedHelp, Nuance and more. What’s an API, why does it matter for health care? Funny you should ask but Andy Oram from O’Reilly Radar wrote an article for THCB all about it!–Matthew Holt

As the health care field inches toward adoption of the computer technologies that have streamlined other industries and made them more responsive to users, it has sought ways to digitize data and make it easier to consume. I recently talked to two organizations with different approaches to sharing data: the SMART platform and the Apigee corporation. Both focus on programming APIs and thus converge on a similar vision off health care’s future. But they respond to that vision in their own ways. Differences include:

  • SMART is an open source project run by a medical school and is partially government-funded; Apigee is a private company.
  • SMART tries to establish a standard; Apigee accepts whatever APIs its customers are using and bridges between them.

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How a Real Writer Dies

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By Michael L. Millenson

True to his proudly claimed Chicago newspaperman roots, famed movie critic Roger Ebert remained a writer literally up until the moment he died.

“A lot of people have asked me how could Roger have [posted] that column one day and then die the next? Well, he didn’t know he was going to die the next day, and we didn’t expect him to. We expected him to have more time. We were going to go to home hospice. We thought we would take him home, let him enjoy that time, and let him get stabilized. I’ve got to tell you: I really thought he was just tired and that he was going to get better.”

“I want people to know that Roger was still vibrant right up to the end,” his wife, Chaz, told Ebert’s friend, TimeOut Chicago columnist Robert Feder, before an April 7 memorial service. “He was lucid – completely lucid – writing notes right up to before the moment of death,” she said. Only later did it occur to Chaz that Roger had begun signing his initials and dating many of the notes he wrote at the end. “Now I wish I had saved them all,” she said.

It was as if a man who had refused for years to be defined by illness refused to be defined even by death. Ebert spoke openly of being a recovering alcoholic (he stopped drinking in 1979), and when cancer cost him part of his lower jaw in 2006, cruelly taking away his ability to either talk or eat, he did not hide, wrote colleague Neil Steinberg in the Sun-Times, Ebert’s home newspaper. Instead, he forged “what became a new chapter in his career, an extraordinary chronicle of his devastating illness” written “with characteristic courage, candor and wit, a view that was never tinged with bitterness or self-pity.”

Ebert, wrote Roger Simon in tribute, was “a newspaperman’s newspaperman.” As a former Chicago newspaperman myself (at that other paper, across the street), I’m sure Roger Ebert continued to write even after his death.

It’s just that he hasn’t found a way, yet, to send out his copy.

As a long-time reporter for the Chicago Tribune, Michael L. Millenson learned the famous fact-checking fanaticism credo of Chicago journalism: “If your mother says she loves you, check it out.” He is currently president of Health Quality Advisors LLC of Highland Park, IL.

Top THCB Blog Posts of the Last Two Weeks

Practice Redesign Isn’t Going to Erase the Primary Care Shortage (36)

By Jeff Goldsmith

The current thinking is that new technologies, better information and a more scientific approach to the practice of medicine will let doctors do more than ever before, allowing them to leap tall buildings at a single bound, see record numbers of patients and improve their patient satisfaction scores. And that may well turn out to be true, argues the University of Virigina’s Jeff Goldsmith, but we’re still faced with a problem that is not going to go away until we come up with a solution: a shortage of living, breathing human beings with medical degrees going into primary care.

Wellness Programs Aren’t Working.
Three Ideas That Could Help (25)

By Mike Miesen

Do wellness programs work? Recently, the heretical idea that they might not actually be all they’re cracked up to be has been gaining ground. Faced by mounting evidence that much of what we’re doing in wellness isn’t working very well, a lot of people are sitting down to work on the problem. How to build new programs that do better? Simple technologies and the right data are the answer, argues THCB contributor Mike Miesen.

JAMA EHR Study: Misdiagnosis Poses Serious Potential For Harm (18)

By Evan Falchuk

A new study published last month finds that misdiagnosis is a serious problem in American hospitals. Could electronic medical records help remedy the situation? Writing from Boston, Evan Falchuck argues that the key to dealing with this problem may be a rethink of how we do medicine in the age of digital health.

A National Caregiver Corps:
What the Administration Could Do (17)

By Janice Lynch Schuster

With millions of Americans nearing retirement age, the healthcare system is ill-prepared with another influx of patients, some critics argue. Throw in a healthcare system in transition, an uncertain economy and a deteriorating safety net and you have downright scary situation. Faced with this crisis, writes Janice Lynn Schuster,  the administration should create a national caregiver corps similar to the Peace Corps or Americorps, enlisting Americans to help protect the well being of vulnerable generations. Add technology to the mix and you just might have something.  We urge you to sign her petition.

Why Become A Doctor? (13)

By Vineet Arora, MD

Confronted with stories of burnout, liability issues, student debt and an uncertain forecast for many popular specialties, many young medical school candidates are looking elsewhere. The rules of the game are changing and changing quickly argues the University of Chicago’s Vineet Arora, but the argument for going into medicine is still compelling.
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Health Reform Should Include Legal Care for Patients

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By Joel Teitelbaum & Tom Koutsoumpas

If the country is serious about reforming the healthcare system, then it needs to look beyond just improving access to medical care.  Reforms must acknowledge and address the underlying causes of poor health, many of which cannot be adequately treated by healthcare professionals alone.  Indeed, for some 50 million low-income Americans, the barriers to getting healthy represent unmet legal needs better remedied by a lawyer than a healthcare professional.

Unenforced sanitary codes leave families living in unsafe housing where children are made sick by mold, or made sicker by the fact that utilities in their homes have been wrongly shut off.  Health system complexities and inefficiencies prevent seniors from benefitting from the insurance and long-term care coverage to which they are entitled, and keep wounded veterans from accessing durable medical equipment such as a wheelchair or other crucial supports.  In each of these cases, traditional healthcare services – no matter how expertly administered, and no matter how capable and compassionate the clinician – will not improve individuals’ health.  Rather, legal assistance is crucial to negotiate with landlords and utility companies, appeal denied insurance claims and expedite access to veteran benefits and services.

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Washington’s New Open Source IT Law Could Change Everything. Let’s Count the Ways …

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By Edmund Billings, MD

In these politically polarized times, Americans expect Republicans and Democrats to disagree on every detail right down to what day of the week it is. This is especially true in the posturing hurly-burly of the House, where members can appeal to the few select priorities of a gerrymandered district to win re-election.

So it’s remarkable and unexpected when any legislation exits a House committee with unanimous bipartisan support. It’s even more surprising when the legislation potentially threatens the status quo for established corporate interests—in this case information technology companies.

The Federal Information Technology Acquisition Reform Act (FITAR)—sponsored by California Republican Darrell Issa along with Virginia Democrat Gerry Connolly, and supported by every member of the House Oversight and Government Reform Committee—threatens to put open-source software on par with proprietary by labeling it a “commercial item” in federal procurement policies. The proposal wouldn’t give open source a privileged position, just an equal one.

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Why Medicare Cuts Will Quietly Kill Seniors

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By MICHAEL L. MILLENSON

The recent news that thousands of seniors with cancer are being denied treatment with expensive chemotherapy drugs as a result of sequestration-mandated budget cuts raises the question of whether other patients are being equally harmed, but less visibly.

A careful study of the impact of past federal budget cutting suggests a troubling answer. That study, in a National Bureau of Economic Research Working Paper published in 2011 and revised last year, established an eerily direct link between slashing hospital reimbursement and whether Medicare patients with a heart attack live or die.

Using data from California hospitals, researchers Vivian Y. Wu of the University of California and Yu-Chu Shen of the Naval Postgraduate School examined mortality rates for heart attack patients following the Medicare payment cuts resulting from the Balanced Budget Act (BBA) of 1997. The impact of the BBA was not as sudden or clear as the current situation, where Medicare’s two percent across-the-board cut on April 1 instantly transformed some expensive chemotherapy drugs into money losers, but it was significant and long-lasting.

The researchers examined hospitals claims data for a three-year period before the BBA, a three-year period when the BBA first took effect and, finally, a six-year period after budget cuts had either permanently changed care or failed to do so. They also tried to adjust for the severity of illness of the heart attack patients – the condition is formally known as acute myocardial infarction (AMI) – and other factors.

In the end, the researchers were able to trace a clear path from Congressional budget decisions to the patient’s bedside. Payment reductions triggered by the BBA , Wu and Shen concluded, led to “worse Medicare AMI patient outcomes, and more importantly, that the adverse effect only became measurable several years after the policy took place.”

They even quantified the effect: every thousand dollars of Medicare revenue loss from the BBA translated to a six to eight percent increase in mortality rates from heart attack.Continue reading…

Twitter Study of Vaccine Messages: Opinions Are Contagious, But In Unexpected Ways

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By Beth Skwarecki

Remember 2009? The H1N1 pandemic we were all waiting for? I do. I was pregnant; H1N1 was particularly risky for pregnant women. The vaccine wasn’t available until after I had my baby, but when they held a clinic an hour north of where I live, I brought my husband there so we could both get our shots. My infant son was too young to be vaccinated, so I wanted to protect him through herd immunity.

A study came out recently on twitter messages from that time. How did pro-vaccine sentiments spread, versus anti-vaccine ones? Which messages were more contagious?

I talked to one of the authors, Marcel Salathe, today. He’s an infectious disease researcher studying the spread and transmission, not (just) of disease, but of information. “We assume people infect each other with opinions about vaccinations,” he said, and the H1N1 scare was a good opportunity to put some of his group’s theories to the test.

They collected nearly half a million tweets about the H1N1 flu vaccine. In 2009, H1N1 wasn’t included in the regular flu shot, and became available partway through flu season as a separate dose. With a possible pandemic looming, people had plenty of motivation to get the vaccine and encourage others to get it—butanti-vaccine sentiments were in circulation too.

The result, striking but perhaps not surprising: negative opinions were more contagious than positive ones. (Specifically, someone who read a lot of anti-vaccine messages was more likely to follow up by tweeting or retweeting negative messages of their own.)

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