Tag: Paul Levy

How to Stop a Future Cancer Epidemic

Oct 29, 2012• 5

By Paul Levy

The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life. But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven. We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).

Here’s the story, from MGH’s James Michaelson, PH.D., arguably one of the most thoughtful, trustworthy, and sensible researchers in the field of analysis of cancer survival. Jim and his team develop sophisticated mathematical methods for predicting the risk of local, regional, and distant recurrence. He says:

There are a couple of good papers about Human Papilloma Virus (HPV), and the coming epidemic (yes, an overused term, but truly applicable here) of head and neck cancer. As Chaturvedi et al say in a recent paper: “If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.”

I get to see this problem from two angles: From my work as the the manager of the MGH/MEEI Head and Neck Cancer Database, and from my experiments in using computer telephone messages to get patients in for preventive health services, such as the fabulous HPV Vaccines: Cervarix (from GlaxoSmithKline) and Gardasil (from Merck). The vaccines are incredibly underutilized. Only about 1% of eligible boys and only 50% of eligible girls get one shot. Only about 25% of girls get all three shots.

Continue reading…

Is the Nurse Incompetent?

Oct 25, 2012• 22

By Paul Levy

This case is prompting a lot of comments, some of them taking issue with the concept of systemic failures and instead asserting that the young nurse was clearly incompetent, in that her error was inexplicable. So, let’s turn from a clinic in Brazil to a recent case in a hospital in the US, cited in this article on AHRQ’s Web M&M. A summary:

The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV. The drug-dispensing machines stocked phenytoin in 250 mg/1 mL vials. The correct dose therefore would require 4 vials and be equal to 3.2 mL to be added to a small IV bag. The nurse misread the order as 8000 mg (8 g) and proceeded to administer that dose to the patient, which was a 10-fold overdose and 2 to 3 times the lethal dose. The patient died several minutes after the infusion.

This nurse had to work hard to make the error:

An audit of the pharmacy system revealed that the nurse had taken 32 vials out of 3 different pharmacy dispensing machines to accumulate 8 g of IV phenytoin. Moreover, the nurse had to use two IV bags and a piggyback line to give that large a dose.

Continue reading…

The Stockholm Syndrome and EMRs

Oct 18, 2012• 9

By Paul Levy

First the definition:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Now, the health care connection. As a result of the billions of dollars allocated by Congress to health information systems as part of the stimulus program, those companies who had a head start in implementing electronic medical records quickly found themselves in demand. Of all those companies, Epic is the most successful. Forbes notes, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.” Here in Massachusetts, the biggest convert was Partners Healthcare System: “System development and implementation will occur over a 10-year period and represent a capital investment of approximately $600 – 700 million.” Elsewhere, notes Forbes: “The biggest win: a $4 billion project to digitize medical records for health care giant Kaiser Permanente.”

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems. The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced. And yet, large hospitals sign up for the system, rationalizing that it is the best. For example, Partners said, “The new health care landscape will challenge us to engage in population health management, improve the coordination of health care, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges.”

Let’s Do the Numbers

Aug 17, 2012• 10

By Paul Levy

Julie Creswell and Reed Abelson offer a story in the New York Times about the HCA for-profit hospital system, noting “A giant hospital chain is blazing a profit trail.” The HCA story and similar ones about other hospital chains financed by private equity force us to consider how a such firms can achieve a return on equity that satisfies investors.

The answer is that they cannot, if we think about running the business on a long-term basis. What makes it work is extracting cash and the exit strategy, the heart and soul of private equity.

As Warren Buffett might say, let’s keep this simple. A for-profit hospital system has the following disadvantages vis-a-vis a non-profit hospital system: (1) Its finances are a mixture of equity and taxable debt, both of which are more expensive than the nontaxable debt of a non-profit; (2) it pays taxes–federal and state income tax, property tax, and sales tax–on which the non-profit is exempt; and (3) it is an unattractive vehicle for charitable donations, compared to the tax-advantages offered donors of non-profits.

These are hefty financial advantages for non-profits, which nonetheless are fortunate if they are able to earn an operating margin of 3%. Admittedly, that’s 3% of revenues, not a 3% return on capital.

An equity investor in a for-profit doesn’t care about margin, strictly speaking, but rather is focused on the rate of return of his or her investment. But let’s stick with the operating margin just for a moment, and let’s just accept that a 3% margin would not generate the kind of equity return demanded by the market place: You pick the hurdle rate: 15%, 20%, 25%, more? It doesn’t matter. A three percent margin just doesn’t get you there.

A (Real) Tragedy at the CDC

Jun 18, 2012• 9

By PAUL LEVY

At the recent Health Care Quality Summit in Saskatoon, Sarah Patterson, the Virgina Mason Medical Center expert on Lean process improvement, noted, “I’d rather have no board rather than an out-of-date board. They have to be real.” She was referring to the PeopleLink Board that is placed is key locations in her hospital to provide real-time visual cues to front-line staff as to how they are doing in meeting quality, safety, work flow, and other metrics in the hospital.

Now comes the CDC, announcing in April 2012, that 21 states had significant decreases in central line-associated bloodstream infections between 2009 and 2010.

CDC Director Thomas R. Frieden, said “CDC’s National Healthcare Safety Network is a critical tool for states to do prevention work. Once a state knows where problems lie, it can better assist facilities in correcting the issue and protecting patients.”

I am trying to be positive when progress is made, and I am also trying to be respectful of our public officials — whom I know to be dedicated and well-intentioned — but does Dr. Frieden really believe that posting data from 2009 and 2010 has a whit of value in helping hospitals reduce their rate of infections?

Try to imagine how you as a clinical leader, a hospital administrator, a nurse, a doctor, a resident, or a member of the board of trustees would use such data. Answer: You cannot because there is not use whatsoever.

I am also perturbed by the CDC’s insistence on using a “standardized infection ratio” as opposed to a simple count of infections or rate of infections per thousand patient days.

Have We Not Been Looking at Things We Should Have Seen?

Sep 13, 2011• 1

By PAUL LEVY

A remarkable aspect of the Parkland Memorial Hospital saga was the degree to which the hospital’s Board was not given information by senior management about the clinical outcomes in their hospital. The lack of transparency, in other words, even went to management’s relationship with its fiduciary board.

A recent article by the Dallas Morning News outlines some of these points:

On August 19, the hospital’s seven-member board of directors got its first chance to read the full report by the U.S. Centers for Medicare & Medicaid Services. Almost 10 days had passed since [the CEO] first received the findings. As members began leafing through pages of the report, surprise, even shock, began to register.

The Chair of the board said, “We had direct culpability, but none of us even knew we were in the report.”

Time to Make Joint Commission Surveys Public

Sep 11, 2011• 1

By PAUL LEVY

Can anyone doubt that the recent kerfuffle faced by Parkland Memorial Hospital in Dallas would have had a greater chance of being avoided if earlier reviews by the CMS-designee, the Joint Commission, would have been made public? Yet, JC surveys are held in confidence. This is a matter of federal law.

Currently, the results of hospital accreditation surveys cannot be accessed by the public under Section 1865 [42 U.S.C. 1395bb] (b) of the Social Security Act, which reads as follows:

“(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by[615] the American Osteopathic Association[616] or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.”

When I was CEO of a hospital, we voluntarily made our JC surveys public, posting them on our corporate website. We felt that it was important for all staff in the hospital to have the chance to review the findings and act on them, and we also felt that public confidence in our hospital would be enhanced by this kind of transparency. While this practice has spread somewhat, most hospitals still do not make their surveys public.

The Emperor Remains Unclothed

Aug 23, 2011• 33

By PAUL LEVY

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs. But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense. They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight: “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare. Elected officials hate being blamed for directly restricting access to medical treatments — even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology: “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals. This can happen only if we change our fee-for-service payment system.”

Peter Pronovost is a Liar. He Must Be. Isn’t He?

Aug 23, 2011• 1

By PAUL LEVY

Peter Pronovost and his subversive friends are at it again. Imagine, first they assert that implementation of a standard protocol and checklist could reduce the rate of central line associated bloodstream infections.

“It wouldn’t work here. Our patients are sicker.”

Then, to make matters worse, they go and contend that reducing the rate of central line infections saves money. Here’s the abstract from the American Journal of Medical Quality:

This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover.

Decision Fatigue. For Doctors, Too?

Aug 22, 2011• 2

By PAUL LEVY

This article by John Tierney in the New York Times suggests that humans suffer from decision fatigue, the tendency to make worse decisions as you make a series of hard decisions as the day goes along. Here are some pertinent excerpts:

No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price. It’s different from ordinary physical fatigue — you’re not consciously aware of being tired — but you’re low on mental energy. The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences. The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice. Ducking a decision often creates bigger problems in the long run, but for the moment, it eases the mental strain. You start to resist any change, any potentially risky move. Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. Continue reading…