Month: December 2015

The Ten Worst Wellness Programs and What They Do to Harm Employees

Dec 4, 2015• 4

By AL LEWIS and VIK KHANNA

If corporate wellness didn’t already exist, no one would invent it. In that sense, it’s a little like communism, baseball, or Outlook.

After all, why would any company want to purchase programs that damage morale,reduce productivity, drive costs up…and don’t work 90%-95% of the time? And that’s according to the proponents. What the critics say can’t be repeated in a family publication such as ours.

Still, those are the employers’ problems. However, the employers’ problems become the employees’ problems when employees are “voluntarily” forced to submit to programs that are likely to harm them. (As the New York Times recently pointed out, there is nothing voluntary about most of these programs.)Continue reading…

The Meaning of “Value” in Health Care

Dec 3, 2015• 15

By PAUL KECKLY

There are terms in healthcare circles that get thrown around as if there’s a common and widely accepted definition.

Consider “quality:” every hospital touts its quality, every physician confidently affirms their delivery of high quality care, and every trade and professional sector in healthcare has its own definition that aligns with attributes of quality they deem most important. “Quality” is touted on every website and in every boardroom, but rarely is it defined and measured consistently.

“Outcomes” is another. Most ascribe positive outcomes in their performance, but the indicators on which they’re based and the time periods over which they’re captured—days, weeks, months, or years—varies from user to user. Valid and reliable measures are ephemeral: process measures are used more frequently because they’re easier for regulators, policymakers and payers to monitor; i.e. “advising a patient to stop smoking or lose weight” but these may have little to do with the actual outcome.

On the Preventability of Lethal Errors: A Response to Dr. Koka

Dec 3, 2015• 3

By JOHN T JAMES, PhD

In my opinion, the title of Dr. Koka’s post (“Very Bad Numbers“) is far too inflammatory for a subject that needs to be taken seriously. Dr. Koka’s summary of the approach I took in my JPS study is a reasonable summary, minus a few key points. Preventability of lethal errors is the problematic issue. The nine authors of the Classen paper did postulate that virtually all serious adverse events they found are preventable; I did not pull this out of the air. Preventability is a highly subjective area. A few years ago everyone assumed that hospital acquired infections were simply the cost of doing business. Now we know that the majority of infections can be prevented. The major difference Dr. Kota and I have is that he wants to rely exclusively on the Landrigan study, which is an excellent and large study, but it is not representative of the nation. It represented hospitals in North Carolina. That state was chosen because it was much more aggressive in efforts to reduce medical harm than the average state in the nation. The OIG study (2010) was in fact an attempt to be representative of the Medicare population across the country, but it is just Medicare beneficiaries. As I noted in my paper, none of the four studies can stand alone, not even the Landrigan paper.Continue reading…

The Healthcare System Link in the San Bernardino Shootings

Dec 2, 2015• 14

By JOE FLOWER

Another day, another mass shooting. At this point the news reports say nearly 30 down, 14 or more dead, multiple perps, at a banquet for the San Bernardino, California, Department of Public Health.

And instantly the argument is all about the guns. I understand that, and I’m not even saying that it’s not about the guns.

And instantly we want to say these folks are crazy and of course that’s true. It doesn’t matter if they frame their reasons around Allah or “no more baby parts” or Obama’s impending takeover of the U.S. using ISIS fascist armies disguised as Syrian refugees pouring over the border from Mexico, doesn’t matter. Anyone who turns a gun on other human beings in a school, a clinic, a public street is we can safely say, nuts, if “nuts” has any real meaning any more.

But there are crazy people in every culture, and we have always had crazy people in ours. The percentage of people who are crazy does not scale across societies and across time with the number of people walking into theaters, malls, and bus stations with guns blazing.

Even the number of guns per capita, or the caliber and size of magazines people can buy, or the rules around buying them do not scale directly with mass violence. There is something else going on here.

Rethinking our Thinking about Diagnostic tests: There is nothing Positive or Negative about a Test result

Dec 1, 2015• 4

By ROBERT McNUTT, MD & NORTIN M HADLER, MD

Making a diagnosis is easy if the test we use to make the diagnosis defines the disease. These sorts of tests, called “reference-standard” tests, when present at any level of the test’s result, make the diagnosis. A spinal fluid culture growing listeria or opioids in the urine are examples.

Using reference-standard tests in clinical medicine, however, is not the norm. The reason for this is that reference-standard tests often don’t exist and if they do they may be dangerous, difficult to obtain, and costly. Hence, we use most often non-reference standard tests that can only raise or lower the likelihoods of diseases. There is nothing particularly new in these comments. Every reader will know such concepts as, the “sensitivity and specificity” of a test. Every reader will remember hearing about, or be able to construct, 2X2 tables showing the sensitivity of a test; the corresponding false negative percent; the specificity of the test; the corresponding false positive percent.

But, despite the ever-present teaching of how tests ‘work”, it is my experience that physicians and patients have difficulty using the measures of a test’s value in clinical care. This difficulty is manifest in the observation that diagnosis mistakes may be common and the perceived mistake is the inciting event in up to 40% of malpractice cases. If the conceptual ideas for appropriate test characteristics are so clear and well taught, why is there so much difficulty in using tests to make a correct diagnosis? I contend that the way we teach and understand testing has not allowed us to advance an ideal, numerate approach to accurately making a diagnosis. I claim, also, that the concept of a single “sensitivity and specificity” for a test is actually suspect, even incorrect.