Category: Uncategorized

The Acute Model

Oct 12, 2011• 2

By BOB WACHTER, MD

Besides studying patient safety and watching all five seasons of The Wire, my other major goal for my London sabbatical was to understand the way the Brits organize hospital care. Mirroring the U.S. hospitalist movement, a new field—called “acute medicine”— emerged about 15 years ago and became the country’s fastest growing specialty.

But there is a key difference: acute physicians are hospitalists working inside a smaller box, the acute medical unit. While the young field has enjoyed some striking successes, I recently spoke at its national conference and challenged acute physicians to be a bit more ambitious—to put a little more of the “disruptive” in their disruptive innovation.

To understand the different evolutionary paths of the U.S. and UK’s systems of hospital care, it’s important to understand the primordial seas from which hospitalists and acute physicians emerged. Whereas the U.S. hospitalist model has all-but-replaced a system in which the primary care physician was expected to be the physician-of-record in the hospital, the UK never had such a system. Instead, general practitioners in Britain have always confined their work to the outpatient world; patients in need of hospital care have been handed off to different physicians since the days of Alexander Fleming. But the traditional model has been for those physicians to be subspecialists, with patients admitted to wards run by consultants: the GI ward, the endocrine ward, the geriatrics ward, and so on.

There are clearly certain diseases—acute MI and stroke come to mind—in which such narrow, specialty-focused wards deliver better outcomes of care. But for the vast majority of hospitalized patients, who are rarely cooperative enough to have just one thing wrong with them, the requirement to pigeonhole patients into a specialty unit is problematic. A 2002 American study found that when patients happened to be cared for by the “wrong” specialist (the cardiology service, say, taking care of an asthma patient), both lengths of stay and mortality rates spiked.

Orphan Innovations

Oct 11, 2011• 2

By TIMOTHY WILSON

If someone has invented a successful, innovative, cost-effective social program, doesn’t it seem likely that it would spread quickly to other communities? Susan Evans and Peter Clarke have written a fascinating article detailing why many programs become “orphan innovations” that no one else adopts.

The authors describe a program started by a retired produce wholesaler in Los Angeles, who convinced distributors to donate slightly spoiled produce to food banks. Before long, poor families were receiving fresh fruits and vegetables that would have been dumped in landfills. Evans and Clarke took it upon themselves to make sure that this program was adopted in other cities, but ran into many roadblocks, such as skepticism from overworked local officials that the program would work. Eventually, through sheer determination, they succeeded: the program spread to dozens of communities. But it took 20 years of hard work, creativity, cajoling, and financial support.

Their conclusion? A social program cannot simply be transferred from one locale to another. Instead, it has to be customized at each new location. Unlike a fast food chain, that plops a carbon copy of a restaurant down in every community in American, social programs have to be adapted to the particular staff, clients, and ecology of each setting.

There are valuable lessons to be learned here for those of us interested in social psychological interventions that improve human welfare. There is a growing movement to translate social psychological theory into interventions that help people in the real world, including ones that help people recover from traumatic events, prevent child abuse, reduce adolescent behavior problems, and close the achievement gap in education (as I chronicle in my book Redirect). Critically, these interventions are being tested with well-controlled experiments, to see if they work. This is a huge advance over relying on common sense, which has led to the wide-spread adoption of programs that don’t work or do harm (see my earlier post, Testing, Testing).

Paul Ryan Is Right (And Wrong)

Oct 11, 2011• 5

By Roger Collier

Having cost the Republican Party a Congressional seat earlier this year with his plan to turn Medicare into a voucher program, House Budget Committee Chair Paul Ryan is back with an even more sweeping health care proposal.

Ryan’s latest offering, unveiled in a speech a week ago at Stanford University’s conservative Hoover Institution, is nothing less than a blueprint for replacing the Affordable Care Act with a consumer-driven model that would eliminate the current tax-exempt treatment of employer-paid health insurance.

Is Ryan right? Or wrong?

Ryan believes that exempting health care benefits from employee income tax leads to insurance choices that are unnecessarily costly (since they are effectively subsidized), insufficiently tailored to employee needs (since few choices are offered), inadequately valued (since the employee isn’t paying), and unreasonably tie employees to their jobs (since they may not be able to move without switching insurance). He also believes the present system is unfair: higher-paid employees get a greater tax advantage, while employees of smaller businesses have fewer (or no) options at higher prices than their peers in larger corporations.

He’s right! Common sense says that people are likely to choose the most generous coverage available if it is free or offered at a very low price, while employers—especially those who must negotiate union contracts—see tax-subsidized health insurance as a “better buy” than salary payments.

Reforming the NPDB: An Open Letter

Oct 10, 2011• 1

Kathleen Sebelius, Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Mary K. Wakefield, Administrator
Health Resources and Services Administration
5600 Fishers Lane
Rockville, MD 20857

Re: Public Use File of the National Practitioner Data Bank

Dear Secretary Sebelius and Administrator Wakefield:

The undersigned are academic researchers who work in the areas of public health, health care quality/patient safety, medical liability, and related fields. (Signatories are listed alphabetically by last name. Academic affiliations are provided for purposes of identification only.)

We write to condemn, in the strongest possible terms, HRSA’s recent decision to make the Public Use File (PUF) of the National Practitioner Data Bank (NPDB) unavailable. We also request that HRSA restore the PUF’s availability immediately.

The NPDB is the only nationwide database of closed medical malpractice claims that is publicly available to researchers. Academics use it extensively. A search on “National Practitioner Data Bank” in Google Scholar’s “articles and patents” database returned a multitude of hits. The same search run in WESTLAW’s “journals and law reviews” database returned 576 articles. In PubMed, the search generated 399 articles. Not all of these articles contain new empirical findings, but many do, and the sheer number of publications attests to the NPDB’s importance. The NPDB is an indispensable resource for academic researchers.

Why Drug Company-Doctor Interactions Are Good For Patients

Oct 10, 2011• 3

By Diane Bieri

Transparency is a powerful tool. Framed properly to illustrate the collaboration between America’s biopharmaceutical companies and physicians, it can empower patients to become more engaged in the care they receive. Transparency can also lead to misinterpretations, discouraging even the most ethical, unbiased doctors from future collaborations that could improve patient health.

ProPublica, whose reporters, Tracy Weber and Charles Ornstein, penned The Times’ Sept. 8 Op-Ed article, “What the doctor ordered,” recently updated its “Dollars for Docs” database of doctors who have received money from biopharmaceutical companies. By listing only names and compensation figures with limited context, patients may assume their care is compromised by tainted doctors. Such an incomplete picture creates unnecessary confusion and, in most cases, is completely unfounded.

We agree with ProPublica that patients should know that many physicians work with biopharmaceutical companies. To be completely transparent, however, they should also know why it benefits them and how the relationship is closely managed to ensure it remains ethical.Continue reading…

The Rise of Big Data

Oct 10, 2011• 6

By MARGALIT GUR-ARIE

Health care is in the process of getting itself computerized. Fashionably late to the party, health care is making a big entrance into the information age, because health care is well positioned to become a big player in the ongoing Big Data game. In case you haven’t noticed computerized health care, which used to be the realm of obscure and mostly small companies, is now attracting interest from household names such as IBM, Google, AT&T, Verizon and Microsoft, just to name a few. The amount and quality of Big Data that health care can bring to the table is tremendous and it complements the business activities of many large technology players. We all know about paper charts currently being transformed via electronic medical records to computerized data, but what exactly is Big Data? Is it lots and lots of data? Yes, but that’s not all it is.Continue reading…

Steve Jobs, Health Care Apps & Me

Oct 10, 2011• 5

By Michelle Snyder

When I heard the news about Steve Jobs on Wednesday, I was surprised at how profoundly sad I felt. Although I had never met him, my company had the thrill of sharing the stage with Steve when Apple announced they would open their platform to third party developers. At the time, I was head of marketing and subscriptions for Epocrates, then best know for our Palm Pilot application for physicians.

At the time, we thought we had done a pretty good job of disproving the old notion that physicians are slow to adopt new technologies. Steve was about to show us our full potential.

It was a surprise for us to be up on that stage, to say the least. Our fellow presenters were industry giants: EA, AOL, SalesForce, Sega and…us. The Sesame Street song ran through my head – “one of these things is not like the other.” Naturally, we were thrilled, but we had no idea how profoundly our company and industry were about to change.

Before the iPhone, Epocrates had built a great business creating drug, disease and formulary content for mobile devices. We launched our first product in 1999 with the premise that physicians were mobile and wanted to access information anywhere, anytime. Health care professionals loved their Palm Pilots – and I still have a bag of Palm IIIs, VX, Tungsten, Handspring, and Treo devices to prove it! Business was going well and we had grown to 25% of U.S. physicians. But we faced a challenge – we had already saturated the market of physicians with a device – and growth of the mobile device market had stagnated.

To this day, I don’t really know how we ended up that stage. But I like to believe the story we were told. Apparently, Steve asked one of his personal physicians why she wouldn’t switch to an iPhone and she replied “because I can’t use Epocrates on it.” True or not, we got an invitation from Apple to be one of their very first third party developers.Continue reading…

Why Doctors Don’t Like Electronic Health Records

Oct 7, 2011• 82

By RICHARD REECE, MD

Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

How Patients Think

Oct 6, 2011• 8

By Kenny Lin, MD

Recently, I had a conversation with Shannon Brownlee (the widely respected science journalist and acting director of the Health Policy Program at the New America Foundation) about whether men should continue to have access to the PSA test for prostate cancer screening, despite the overwhelming evidence that it extends few, if any, lives and harms many more men than it benefits. She felt that if patients could be provided with truly unbiased information and appropriate decision aids, they should still be able to choose to have the test (and have it covered by medical insurance). Believing that one of the most important roles of doctors is to prevent patients from making bad decisions, I disagreed.

After reading Your Medical Mind, the new book by Harvard oncologist and New Yorker columnist Jerome Groopman, I think he would probably side with Brownlee’s point of view. Groopman, whose authoring credits include the 2007 bestseller How Doctors Think, and wife Pamela Hartzband, MD have written a kind of sequel to that book that could have easily been titled How Patients Think. Drawing on interviews with dozens of patients about a wide variety of medical decisions – from starting a cholesterol-lowering drug, to having knee surgery, to accepting or refusing heroic end-of-life interventions – the authors explore many of the factors that influence people’s health-related choices. The result is a compelling narrative that seamlessly blends “rational” factors such as interpreting medical statistics and decision analysis with personal factors such as past experience, emotional states, and personality styles.

FDA Should Consider Cost in Some Decisions

Oct 5, 2011• 3

By STEVEN GROSSMAN

FDA decides whether drugs, biologics and medical devices are safe and effective and can be marketed legally in the United States. The agency analyzes risk-benefit, but never cost. In contrast, public and private insurers, along with physicians and pharmacists, have the responsibility for cost-benefit decision making.

I have always felt quite strongly that this was the right way to allocate roles. Safety and efficacy determinations are difficult enough without weighing cost, so keeping a barrier between them makes sense. Two events this past week have left me wondering whether there are certain limited circumstances when FDA should be able to take product cost into consideration.

On September 26, 2011, The Oncology Commission of the British medical journal, Lancet, released a report entitled: “Delivering Affordable Cancer Care in High-Income Countries.” The 40-page report is wide-ranging, but its conclusion straightforward: as cancer care grows more expensive (and it is doing so at a rapid pace), affordability, accessibility and value are issues that need to be confronted aggressively.