The American Society of Clinical Oncology recently made public nearly all of the abstracts — more than 5,000 pieces of research — that were selected for the ASCO annual meeting, which kicked off in Chicago on the last day of May.
Sifting through those 5,000 abstracts would be an almost inhuman task: each abstract contains 2,000 characters. That’s 10 million characters of information about oncology created by experts that’s now available for the public to parse.
But as remarkable as the ASCO abstract drop is, that research is not the only overwhelming trove of communication on cancer created by doctors. One ASCO abstract (based on research by me and W2O colleagues Greg Matthews and Kayla Rodriguez) tells story of how, over the course of 2013, U.S. doctors tweeted about cancer 82,383 times. At 140 characters a tweet, that’s nearly 12 million characters.
We know there were 82,383 tweets because we counted them. Using our MDigitalLife database, which matches Twitter handles with verified profiles from the government’s physician database, we scanned all tweets by doctors for mentions of dozens of keywords associated with cancer over the course of calendar year 2013.
Given the attention now paid to implementing national health reform, the bulk of which is now upon us as 7 million new individuals now have health insurance, one important issue remains largely ignored by policy makers and industry leaders–health care workers are very unhappy.
A 2012 national survey of 24,000 physicians across all specialties found that if given the choice, just over half of these doctors — only 54 percent — would choose medicine as a career again. Fifty-nine percent of physicians in a 2013 survey could not recommend their profession to a younger person, and forty-two percent were dissatisfied in their jobs. Forty percent of physicians in another 2013 national survey self-identified as burned out.
Nursing has gained the moniker of one of the least happy jobs in America, with nurses traditionally experiencing high rates of job dissatisfaction, burnout, and turnover. Some of the reason for this malaise among our highest status health professionals has to do with the stressful, uncertain nature of health care work.
But it also is an outcome of the everyday worlds in which all health care workers now find themselves: a world drenched in paperwork, packed patient schedules, and decreased control. In short, the new world of health reform.
We are in the midst of a technological and business revolution in health care delivery. We are also on expanding patient demand in ways not seen in generations. But we are not meeting the needs of health care workers, who are expected to produce at a higher level than ever before.
Ultimately, spending less on health care is a relatively easy task: We either need to consume fewer services, or spend less on the services that we consume. But much like we teach our Kellogg students about maximizing profits, the devil is in the details.
It’s certainly tempting to ask the government to swoop in on a white stallion and solve the all our problems by fiat. For example, we could have the government simply exploit its monopsony power and set prices, but an artificially low price will lead to an inefficiently low quantity of services and future innovation (stay tuned, we will have more to say about this next week).
Similarly, we could explicitly ration quantities (as opposed to implicitly doing it through a large uninsured population). But how could we hope to determine the right level of care? Ultimately, if we ask the government to unilaterally fix this problem, instead of a white stallion we could behold a pale horse and all that it entails.
The good part, perhaps the best part, about the Affordable Care Act is that it attempts to address this problem using market forces. The question is whether we are ready for what these market forces will entail.
We will focus today on the role of market forces in the insurance market to control prices in the newly established ACA exchanges.
This month the Obama administration announced that it would allow insurers to use “reference pricing” for insurance programs in the exchanges. Under a reference pricing system, insurers set the maximum price they will pay for a specific set of services and if patients go to a facility that costs more than that amount they are required to pay the difference.
Beginning about 5 years ago, many US medical schools introduced severe restrictions on marketing activities by pharmaceutical companies and medical device manufacturers.
These measures often prohibited representatives of such firms from entering patient care areas and even medical school facilities, with the exception of tightly controlled training activities, and then by appointment only. In some cases, medical schools have issued outright bans against industry support of educational activities.
What is the rationale behind such actions? It boils down to a concern that industry funding may inappropriately influence both medical education and patient care. For example, a physician visited by an industry representative might be more likely to prescribe one of the firm’s drugs. In announcing a ban on such activities, one school likened the industry to Don Juan, worrying that physicians might prescribe drugs because they were “seduced by industry,” and not because “it’s best for the patient.”
There is evidence that even physicians who believe their decision making is not biased by marketing are in fact affected by it. Moreover, a good deal of such marketing is not exactly purely scientific. A perusal of medical journals reveals a plethora of full-page ads featuring slogans such as:
“Simplicity is clear information at your fingertips,” and highlighting images such as a physician walking down a hallway with a tiger, describing the featured drug as a “powerful partner.”
Such marketing is not inexpensive. Placing a full-page ad in a medical journal typically costs around $4,000. On the other hand, as an air traveler I have come across a number of slick full-page airline magazines ads touting medical schools and their affiliated hospitals.
“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.
We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.
What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.
But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.
Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.
Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.
I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?
At the end of March the Amercian College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint statement saying they “will begin to include value assessments when developing guidelines and performance measures (for pharmaceuticals), in recognition of accelerating health care costs and the need for care to be of value to patients.”
You may have heard of value-based medicine, but are we entering a new era of value-based medications or value-driven pharma?
Price transparency is great, but it has be combined with efficacy to get to value (price for the amount of benefit). Medical groups are catching on to how important value assessments are, because if patients can’t afford their medication, they won’t take their medication, and that obviously can turn into poor outcomes.
Twenty-seven percent of American patients didn’t fill a prescription last year according to a Kaiser Family Foundation Survey. This trend seems likely to continue as we move toward higher-deductible plans, where those with insurance can have great difficulty affording medications.
Included in the ACC/AMA statement was a quote from Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine.
“There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed…These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources.”
Spreading risk and payment to different members of the health care value chain is beginning to make it apparent to more people and organizations that resources are finite. Patients and their physicians are starting to ask which treatments are worth the cost and have best likelihood of adherence.
An outgrowth of the move toward digital health and accountable care is that we’re entering every patient into a potential personal clinical trial with their data followed as a longitudinal study, and we can look much more closely at efficacy and adherence and reasons why it happens and why it doesn’t.
It won’t be long before we start to see comparative effectiveness across a variety of treatments and across a variety of populations. When we can connect outcomes data, interventions and costs all in the same picture we begin to see where the value (price against results) is and where it isn’t.
For those who may not read through to the end, here is the take home: you do not get to tell me how to feel or what my attitude should be, no matter who you are.
Sure, it’s more comfortable for me and the people around me when I’m have a positive attitude, but that does not mean that I have to live “all bliss all the time” like some insane American cable television station. Being positive does not mean pretending that nothing is wrong because… cancer, people!
A young woman who, I think, just turned twenty-two posted this on her Facebook page: “That’s the thing about pain. It demands to be felt.” She knows what she is talking about, by the way.
It does no good to pretend that emotional pain does not exist. It does no good to pretend that it’s not there. The only way I’ve ever found to get through pain is to recognize it, sit with it, walk through it to the other side. Sometimes that process leaks out into the environment and then I don’t smile prettily at everyone around me. Sometimes I’m snotty and bitchy and generally not one of Jesus’ little sunbeams. Sorry about that, but… cancer, people!
Here’s another news flash. A positive, determined attitude will not cure cancer, no matter what the popular media tell you. The following quotations are from the American Cancer Society:
In 2010, the largest and best-designed scientific study to date was published. It looked at nearly 60,000 people, who were followed over time for a minimum of 30 years. This careful study controlled for smoking, alcohol use, and other known cancer risk factors. The study showed no link between personality and overall cancer risk. There was also no link between personality traits and cancer survival.
The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.
What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.
So I would like to know, please, when I’ll get to practice at the top of my license?
As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.
Yet I spend a lot of time performing tasks that could be done by someone with far less training.
Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.
I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.
First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.
This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.
Last year, about 43 million people around the globe were injured from the hospital care that was intended to help them; as a result, many died and millions suffered long-term disability. These seem like dramatic numbers – could they possibly be true?
If anything, they are almost surely an underestimate. These findings come from a paper we published last year funded and done in collaboration with the World Health Organization. We focused on a select group of “adverse events” and used conservative assumptions to model not only how often they occur, but also with what consequence to patients around the world.
Our WHO-funded study doesn’t stand alone; others have estimated that harm from unsafe medical care is far greater than previously thought. A paper published last year in the Journal of Patient Safety estimated that medical errors might be the third leading cause of deaths among Americans, after heart disease and cancer.
While I find that number hard to believe, what is undoubtedly true is this: adverse events – injuries that happen due to medical care – are a major cause of morbidity and mortality, and these problems are global. In every country where people have looked (U.S., Canada, Australia, England, nations of the Middle East, Latin America, etc.), the story is the same.
Patient safety is a big problem – a major source of suffering, disability, and death for the world’s population.The problem of inadequate health care, the global nature of this challenging problem, and the common set of causes that underlie it, motivated us to put together PH555X.
It’s a HarvardX online MOOC (Massive Open Online Course) with a simple focus: health care quality and safety with a global perspective.