To no one rational’s surprise, a study confirms that those few Oregon patients (400 over 10 years) who chose legal physician assisted suicide in case of terminal illness had a better quality of death than those who didn’t. Sadly because those attacking it aren’t rational, this won’t end the debate–but if you’re terminally ill you have better choices in Oregon (and Washington & Switzerland).
Looking For Quality In the Wrong Place
Last week I attended the first annual meeting of the Long-Term Quality Alliance and listened to Gregg Pawlson (a geriatrician and executive with NCQA) talk about quality measurement. Right now, quality measurement does too little to drive practice towards quality care because it is based only on things that are “feasible,” or easy to measure—like what gets coded on medical bills. Pawlson observed that while feasibility must be one of the watchwords of quality measurement for now, in the near future electronic medical records should allow us to move beyond billing codes to gather real clinical data for more important quality measurement, including key care processes and outcomes.
I sure hope so. Because those who have looked beyond the dim illumination of current billing-based “quality measures” and searched in the darkness where real processes of clinical care can found have found that the situation is grave. The ACOVE (Assessing Care of Vulnerable Elders) process, while laborious, looks at clinical care where it really happens – in offices and charts – rather than in bills and therefore has a better chance of driving meaningful quality improvement. Readers know that I am a big fan of this work, begun at RAND by outstanding clinician-researchers including Neil Wenger, David Solomon, David Reuben, and many others. I believe that ACOVE is an example of what we need in elder care: high quality evidence about essential clinical practices that are sensibly related to real health outcomes and show how we could (often easily) do better for older people. ACOVE is a blessing.Continue reading…
Quality or value? A Measure for the 21st Century
One of the founders of the evidence-based medicine movement, Muir Gray
Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?
Well, let’s define the terms. The Merriam-Webster dictionary defines quality as “the degree of excellence.” The same source tells us that value is “a fair return or equivalent in goods, services or money for something exchanged.” To me “value” is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?
Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let’s take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.
But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions — they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?Continue reading…
Conflicts Of Interest In Guideline Development: A Dirty Little Secret Gets Aired Again
By DAVID WILLIAMS
An Archives of Internal Medicine article (Conflicts of Interest in Cardiovascular Clinical Practice Guidelines) is getting a lot of notice this month. In essence, many of the physicians who develop guideline that influence practice patterns and payment decisions have conflicts. The authors recommend only allowing those without conflicts to write the guidelines.
This isn’t a new issue. In 2006 I wrote a piece (Another dirty little secret is out in the open) and am reposting it below because it’s timely:
A year ago in Time to deal with medicine’s dirty little secrets?, I wrote about a variety of practices that are relatively well-known in the health care field but would be shocking to outsiders. Industry often takes the blame for “aggressive marketing tactics,” and no doubt some of that is deserved. But physicians are also culpable.
The open secrets include the ghostwriting of journal articles by industry sponsors, physicians and academic medical centers holding ownership stakes in companies whose products they are researching, the clinical role sometimes played by orthopedic sales reps, and perhaps the most egregious example: physicians who set guidelines having financial relationships with the companies that benefit from how those guidelines are set.
Now we have a new example, which is even more serious than usual. A recent New England Journal of Medicine article blames Eli Lilly for overzealous promotion of Xigris. According to the Boston Globe:
Eli Lilly and Co. funded medical guidelines created for the treatment of [sepsis] in an effort to boost sales of a drug with questionable benefits. The allegation was made by senior scientists at the National Institutes of Health. [They] said Lilly tried to shape the guidelines for use of the drug Xigris by sponsoring a three-pronged marketing campaign
The first two phases are by now almost standard practice in the industry:
- Lilly paid a task force to spread the word that hospitals were rationing Xigris because of its cost, which forced docs “to decide who would live and who would die”
- Lilly “orchestrated” the development of practice guidelines to treat sepsis that called for early use of Xigris (an example of the phenomenon I have described before)
But then Lilly allegedly took a third step, which was a little shocking even to me:
Now, Lilly is sponsoring lobbying efforts to turn the guidelines into quality standards. Hospitals that follow such quality measures receive higher payment from insurers.
What’s happening here? Basically, an influential group of doctors is being lazy and greedy, and Lilly is enabling their behavior. The doctors put their fingers in the cookie jar and Lilly keeps restocking it. The public is paying for the cookies –in the form of higher product sales and sub-optimal health care– and should get fed up!
I have no problem with companies using legal means to promote their products, even if their tactics are “aggressive.” They owe it to their shareholders to maximize return on investment. But it isn’t in their long-term interest to push things as far as the medical profession often lets them.
Industry leans on the reputations of individual physicians (aka “key opinion leaders”), medical societies (aka guideline writers), and journals to legitimize their marketing messages. It’s up to the medical profession to scrutinize industry claims and issue independent guidelines and quality standards. Sometimes these claims hold up and deserve to be propagated. Sometimes they don’t. If the docs and journals don’t do their jobs they deserve to lose credibility.
It’s hard to know the extent to which medical guidelines are already corrupted. The situation is a bit like the incident when the Chinese President’s plane was refitted. In the process of fixing up the plane someone inserted a bunch of listening devices (presumably at no extra charge). When the Chinese checked out the plane and realized it was bugged they had to rip the whole thing up. That’s something like what is going on within the major payers. They’ve stopped treating journal articles and guidelines as objective and have started doing their own analyses. But do we really want to leave health care decisions just to them?
Here’s some free advice to the different players in health care:
- Industry: Feel free to market your products and services aggressively, but don’t take things too far. If you do you’ll end up killing the goose that lays the golden eggs. No one will trust doctors, guidelines or journals anymore
- Physicians: Remember that pharma and device companies are not stupid. If they spend money supporting your research or sending you to conferences or sponsoring continuing medical education it’s because they expect to get a return on their investment. It’s awfully hard to remain objective in such instances. Your job is to adopt the best medical practices and put the patient first –sometimes that requires expensive new treatments and sometimes old, cheap standbys are better
- Payers: Go ahead and challenge the objectivity of journal articles and guidelines. On the other hand, don’t pretend that low cost is always synonymous with best treatment. Expect physicians to keep you in line on that.
- Patients: You need to look out for yourself. Find a good, honest physician. Take a look at who’s sponsoring the educational materials you receive. Ask your physician about alternative treatments and do some research yourself
Two Kidneys and 100,000 Lives
This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.
Of course, such rules already exist, and it was likely a lapse in them that led to this result.
Nonetheless, we will “bolt on” a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.
This kind of coverage and response is a spin-off from the “rule of rescue” that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.
Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine’s studies that documented the number of unnecessary deaths per year.
And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:
An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.
As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”
There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: “When you have a hammer, everything looks like a nail.” Changes in payment rate structures, penalties for “never events,” and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.Continue reading…
Truth or Consequences
By
While we are on the topic of medical errors, let’s see how doctors feel about disclosing them when the patient has not been harmed. Medscape recently surveyed doctors on this question and published the results in a provocative article by Gail Garfinkel Weiss entitled: ‘Some Worms Are Best Left in the Can’ — Should You Hide Medical Errors?” (A subscription is required, but it is free.)
To the doctors reading this, into which camp do you fall? To the patients reading this, what would you expect of your doctor in this kind of situation?
Some excerpts:
In response to the question “Are there times when it’s acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?” 60.1% of respondents answered “no,” and the remaining respondents were almost evenly divided between “yes” (19%) and “it depends” (20.9%).
2010 Unplugged
By BOB WACHTER, MD
For people like me, who, perversely enough, get a certain thrill from studying healthcare policy, there’s never been a more exciting, if also dizzying, year than 2010. Passage of the reform bill last March was only the start – and in some ways merely a marker – of the Shifting of the Paradigms: from provider to system; from pen to keyboard; from pay-for-piecework to pay-for-performance; from secrecy to transparency; from patient as passive actor to patient as star of our show.
I’ve been catching up on my reading during the holidays, so bear with me as I devote this blog – lengthier than usual – to a handful of articles, talks, and experiences that, while seeming unrelated, helped me better understand some of the threads of this vibrant healthcare tapestry we’re now weaving.
For decades, one of the defining characteristics of the American healthcare enterprise has been the remarkably poor value – quality divided by cost – it produces. Most of the changes afoot represent a push by a variety of stakeholders, using the tools at their disposal, to improve this value equation. And much of the push-back can be seen as the predictable acts of those who benefited from the old order. As the late William Safire once observed, when you zap a sacred cow, you need to brace yourself for the ensuing mooing. Welcome to Old MacDonald’s Farm.
Hospitalist Co-Management Of Neurosurgery Patients
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In this month’s Archives of Internal Medicine, my colleagues and I report the results of our early experience with hospitalist co-management of neurosurgery patients. We found stratospheric satisfaction among neurosurgeons and nurses, as well as impressive cost reductions ($1400/admission). At the same time, there was no impact on quality or safety, at least as judged by hard end-points such as mortality and readmission rates.
While these results might seem like a mixed bag, I believe that the overall impact of this service has been fantastic, for patients, surgeons, and our own hospitalists. Let me explain, beginning with a brief history of hospitalist co-management, folding in the history of our neurosurgery co-management effort (which we call the “Co-Management with Neurosurgery Service”, or CNS), and ending with some of the more subtle outcomes that lead me to feel that this is one of the most important things our hospitalist program has done since its inception in 1995.
A Brief History of Co-Management
When the hospitalist field took off in the mid-1990s, we projected that its growth would largely reflect the degree to which hospitalists assumed the care of inpatient internal medicine (and later, pediatrics) patients: those with pneumonia, heart failure, sepsis, GI bleed, and the like. Sure, I recognized that there would be increased opportunities for traditional medical consultation – we come when you call us – but I completely underestimated the siren call of co-management.
It turns out that once there are hospitalists in the house, the notion of having them actively co-manage surgical patients is hard to resist, for several reasons. First, many of the problems such patients experience before and after surgery are really medical, not surgical. Secondly, just as a hospitalist can provide on-site availability that the primary care physician can’t match for medical patients, he or she can do the same for surgical patients. (In this case, it’s not that the primary care doc is stuck in the office, but rather the surgeon is stuck in the OR.) Third, in an era of more widespread quality measurement and reporting, it seems likely that a hospitalist will improve quality measures such as DVT prophylaxis and evidence-based management of CHF more than a surgeon, flying solo, would be able to.
Selecting an EHR for the Patient-Centered Medical Home
The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.
Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation”. Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?Continue reading…
The Wrongologist
Author Kathryn Schulz recently provided a newspaper exposition of some of the themes of her new book, Being Wrong, Adventures in the Margin of Error. As noted on her website, Kathryn has “a credible (if not necessarily enviable) claim to being the world’s leading wrongologist.”
She finds fault in the way we find fault in ourselves. “Misunderstanding our mistakes . . . — seeing them as evidence of flaws and an indictment of our overall worth — exacts a steep toll on us. . . . [I]t impedes our efforts to prevent errors in domains, such as medicine and aviation, where we truly cannot afford to get things wrong.”
The book is engaging and thought-provoking.
Kathryn uses our wrong-side surgery experience at BIDMC as an uncommon example of using error to improve things, particularly when an aggressive target for error reduction has been established and when a commitment to transparency has been adopted.
She notes, “If you really want to be right (or at least improve the odds of being right) you have to start by acknowledging your fallibility, deliberately seeking out your mistakes, and figuring out what caused you to make them.”
(Bostonians can hear Kathryn in a reading this Friday evening at the Harvard Book Store.)
Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.
