Year: 2014

The Ebola Outbreak: The CDC Director’s Guidance for Health care workers

Sep 30, 2014• 52

By Tom Frieden, MD

There has been a lot of fear about Ebola. The health care workers who care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice meticulous infection control measures.

Ebola virus is transmitted through direct contact with bodily fluids of an infected person who is sick with Ebola, or exposure to objects, such as needles, that have been contaminated with infected secretions.

Travel from Affected Region

There is a risk for Ebola to be introduced to the United States via an infected traveler from Africa. If that were to happen, widespread transmission in the United States is highly unlikely due to our systematic use of strict and standard infection control precautions in health care settings, although a cluster of cases is possible if patients are not quickly isolated. Community spread is unlikely due to differences in cultural practices, such as in West Africa where community and family members handle their dead.

CDC has advised all travelers arriving from Guinea, Liberia, Nigeria, and Sierra Leone to monitor their health for 21 days and watch for fever or other symptoms consistent with Ebola. If they develop symptoms, they should call ahead to their hospital or health care provider and report their symptoms and recent travel to the affected areas so appropriate precautions can be taken.

Changing My Mind on SES Risk Adjustment

Sep 29, 2014• 15

ASHISH JHA, MD

I’m sorry I haven’t had a chance to blog in a while – I took a new job as the Director of the Harvard Global Health Institute and it has completely consumed my life. I’ve decided it’s time to stop whining and start writing again, and I’m leading off with a piece about adjusting for socioeconomic status. It’s pretty controversial – and a topic where I have changed my mind. I used to be against it – but having spent some more time thinking about it, it’s the right thing to do under specific circumstances. This blog is about how I came to change my mind – and the data that got me there.

Changing my mind on SES Risk Adjustment

We recently had a readmission – a straightforward case, really. Mr. Jones, a 64 year-old homeless veteran, intermittently took his diabetes medications and would often run out. He had recently been discharged from our hospital (a VA hospital) after admission for hyperglycemia. The discharging team had been meticulous in their care. At the time of discharge, they had simplified his medication regimen, called him at his shelter to check in a few days later, and set up a primary care appointment. They had done basically everything, short of finding Mr. Jones an apartment.

Ten days later, Mr. Jones was back — readmitted with a blood glucose of 600, severely dehydrated and in kidney failure. His medications had been stolen at the shelter, he reported, and he’d never made it to his primary care appointment. And then it was too late, and he was back in the hospital.

The following afternoon, I spoke with one of the best statisticians at Harvard, Alan Zaslavsky, about the case. This is why we need to adjust quality measures for socioeconomic status (SES), he said. I’m worried, I said. Hospitals shouldn’t get credit for providing bad care to poor patients. Mr. Jones had a real readmission – and the hospital should own up to it. Adjusting for SES, I worried, might create a lower standard of care for poor patients and thus, create the “soft bigotry of low expectations” that perpetuates disparities. But Alan made me wonder: would it really?

To adjust or not to adjust?

Because of Alan’s prompting, I re-examined my assumptions about adjustment for SES. As he walked me through the data, I concluded that the issue of adjustment was far more nuanced than I had appreciated.

Graphic Warning Labels on Cigarettes Are Scary, but Do They Work?

Sep 27, 2014• 2

DEBORAH SHARF and WILLIAM SHADEL

Looking at cigarette packaging in some countries, you might think Big Tobacco and AMC have entered into a bizarre cross-promotion for The Walking Dead. You’ll see blood-drenched corpses, facial scars and head wounds, people dying in hospital beds, screaming children, crying women—the list goes on.

These “graphic warning labels” pair gruesome images with warnings about the dangers of smoking, covering anywhere from 30 to 80 percent of cigarette pack “faces” (the front and back). The goals of such labels are informing consumers about the risks of smoking, encouraging quitting among smokers, and preventing others from ever starting.

Research shows people exposed to these labels are understandably repulsed and disgusted. When asked, they express the belief that labels should keep people from smoking. And after viewing them, they have more negative thoughts and feelings about smoking.

But do graphic warning labels actually prevent people from starting to smoke? Do they cause current smokers to quit?

Ceci Connolly: Will Technology Replace Doctors?

Sep 26, 2014• 35

Ceci Connolly

It’s a provocative question, but it’s also the wrong one.

The question ought to be: When will healthcare fully embrace technology and all it has to offer?

It’s widely known that the $2.8 trillion US health system has significant waste and errors – between 25% and 30% of our health dollars go to services that do not improve health. Technology has the ability to put a big dent in that through standardization, real-time insights, convenient gadgets and complex data analysis the human brain simply cannot perform.

Consider some of the early innovators. There’s the heart monitor in the phone. The wristbands that count steps. And then there’s Oto, the cellphone attachment that snaps an image of the inner ear sparing frazzled parents one more trip to the doctor’s office for yet another infection.

Have Doctors Joined the Working Class?

Sep 26, 2014• 19

Richard Gunderman, MD

On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London. Among the attendees was a relatively obscure German journalist by the name of Karl Marx. Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.

The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices. This moves physicians into the category of what Marx and his associates called, “working people.” According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%. And the trend is accelerating. It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.

To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production. In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients. Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.

Surviving Healthcare

Sep 26, 2014• 9

Joe Flower

Health care is fragile. It survives in a much narrower band of circumstances than most of us realize. Right now many hospitals and systems are having a second down year in a row. They’re consolidating, laying off people, working through major shifts in strategy — all because of what we must admit (if we are honest) are relatively minor economic shifts, such as small reductions in utilization and Medicare payments, a blunting of accustomed price rises, and stronger bargaining from health plans.

If minor revenue stream problems put your entire institution in jeopardy of chaotic deconstruction, it cannot be called robust.

At the same time, an increasing number of vectors outside the sealed world of health care could overwhelm and kill your institution, from climate chaos to pollution disasters to epidemics and the loss of antibiotics.

The Org Chart of the Damned

Sep 26, 2014• 1

THCBist

HAT TIP: Mr. Nosta

Ask Me Anything with CDC Director Tom Frieden

Sep 26, 2014• 13

Thomas Frieden, MD

The Ebola outbreak in West Africa is an international public health emergency. As the world responds, there is a risk that American responders working on the ground may be exposed to the virus or become ill. This summer, two American health care workers infected with Ebola while working in West Africa were successfully treated at Emory University Hospital. Their health care team used the proper infection control practices and there was no transmission of the virus to the health care team or others in the hospital and community.

Now two more American health care workers working in West Africa have become infected with Ebola virus and are being treated in the United States.

CDC has already consulted with state and local health departments on almost 100 cases where travelers had recently returned from West Africa and showed symptoms that might have been caused by Ebola. Of those cases, only eleven of were considered to be truly at risk. Specimens from all eleven patients were tested and fortunately Ebola was ruled out in all cases.

There is understandably a lot of fear surrounding Ebola. The health care workers who might need to care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice the meticulous infection control measures we know will prevent transmission of the virus.

Biosurveillance at the Point of Care

Sep 26, 2014• 1

ROBERT ARKIN and JITEN CHHABRA, MD

Living in Atlanta and working within the healthcare delivery innovation community, the mounting Ebola outbreak taught us all how quickly the “global” can become local.

For a healthcare system threatened by infectious disease, complex chronic illness, environmental and population management issues, the outbreak also reinforces how new technologies are advancing patient and caregiver safety, prevention, patient monitoring, diagnosis and even treatment.

The answer, through non-contact medicine, is literally in the airwaves.

Researchers at Stanford are pursuing the combined use of laser and carbon nanotubes to provide a more detailed view of blood flow in the brain – down to single capillaries – to increase the understanding of cerebral-vascular disease beyond the imaging provided by CT scan or MRI.

It’s a Trade-Off, Stupid.

Sep 25, 2014• 17

SAURABH JHA, MD

An advantage of being a foreigner, or a recent immigrant to be precise, is that it allows one to view events with a certain detachment. To analyze without the burden of love, hate or indifference for the Kennedys, the Clintons or the Bushes. To observe with both eyes open, rather than one eye looking at the events and the other looking at a utopian destination.

The most striking thing I’ve observed in the healthcare debate in the US is the absence of an honest discussion of trade-offs.

I’ve found that “trade-off” carries a sinister connotation in American healthcare parlance. Its mere utterance is a defeatist’s surrender. If optimism is the iron core of the United States, acknowledging trade-offs is her kryptonite.

I was raised in Britain. I learnt to guard optimism with pursed lips. You never knew when it would rain. I also learnt in Britain’s NHS where healthcare resources really are finite, there is a trade-off between coverage and access.

In the discussions preceding the implementation of the Affordable Care Act (ACA) two disparate truths were conjoined by a single solution. The unsustainable trajectory of healthcare spending. And the large number of uninsured population. It was scarcely acknowledged that solution of these problems are inherently oppositional.

This has led to the search for utopian payment models. Fee for service incentivizes physicians towards generously reimbursable services of marginal benefits. Capitated systems dissuade physicians from taking sicker patients.

How about we pay for outcome, value and quality? Sounds simple enough.