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Tag: Quality

Knee Trauma, again

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By Matthew HoltMatthewholt

One of my favorite topics is back in the news. Apparently ACL repairs may be unnecessary. Here’s the WSJ Health Blog write up about the NEJM study. Two groups of active young people with torn ACLs were split. Half got immediate ACL repair, half got rehab and later repair if they needed it. Of the second group around 39% needed surgery but when the two groups (surg vs surg when rehab wasn’t enough) were assessed there was no difference.

Mostly this is a big duh! A simple ACL tear doesn’t need fixing unless you are going to go skiing, play soccer, volleyball or some other sport that needs it. I had a left knee simple ACL tear in my early 30s, had it fixed after 6 months wait & rehab and went back to all those sports. (Although I never seriously tested it in a twisting sport before repair).

Then several years later I had both a right knee ACL tear and a few weeks later multiple trauma to my left knee—3 ligament tears and other damage. (Advice to you all; snowboard around the tree not into it). My left knee has never recovered (nor will it) to take part in those twisting sports so I never had the right one fixed (I did get a new ACL & PCL in left knee as I need to be able to walk again!). But the right knee with no ACL is fine for walking, running, biking and even controlled pivoting for snowboarding—where the leg is locked in place vis a vis the other one.

But if I try to twist in a gentle soccer kickabout on my right knee I fall on my ass. So for my earlier ACL repair I suspect that I would have been in the group that needed surgery anyway (the 39%). So if you don’t want to or don’t need to play those sports OR if you do the rehab and are fine, you don’t need a repair, But if you do need to play those sports and rehab alone doesn’t work, then you do.

The question is how many people are getting the ACL repair but never gave rehab a try? Probably quite a few, and for them rehab with the option of surgery is a good idea.

But the real question is how many people are getting ACL repairs when they’re not participants in those sports? Anyone know?

Maybe Being Wrong is Better and More Human than Being Right

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By KENT BOTTLES, MD

St. Augustine: “Fallor ergo sum”

When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters.  I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool.  As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes.  I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom.  Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.

Mistakes and errors are on my mind because I just finished reading some extraordinary works.

Continue reading…

10 Rules for Good Medicine

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By ROB LAMBERTS, MD
Rob Lamberts

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes “good care” in my practice?

So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It’s the Patient’s Visit

The visit is for the patient’s health, not the doctor’s income or ego.  This means three things:

  1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
  2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
  3. All tests done on the patient should be reported to them in a way that they can understand.

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Hospital Quality Group Obscures Hospital Quality Reports, Journalists Charge

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By MICHAEL MILLENSON

The Joint Commission, which accredits four-fifths of the nation’s hospitals, is being accused of misleading consumers about the quality of care at those hospitals and then ignoring suggestions on how to correct the problem.

“The organization that accredits hospitals around the country, and voices support for transparency about hospital quality, has a Web site that obscures the reality of many hospitals’ performance,” said Charles Ornstein, president of the Association for Health Care Journalists (AHCJ) and a reporter for the public-interest journalism group ProPublica . In a March 1 letter sent to Dr. Mark R. Chassin, the Joint Commission’s president and CEO, Ornstein noted that not only has the group not addressed the “navigational issues” raised by AHCJ more than two years ago, but problems that make the commission’s QualityCheck site even less useful have cropped up.

For instance, that “Gold Seal of Approval” for your local hospital? Perhaps it should be called a Gold Seal of Possible Approval. Says the AHCJ: “[It] is misleading because hospitals with conditional accreditation or preliminary denial of accreditation still receive the same gold seal as fully accredited facilities.”Continue reading…

The five things to pay attention to in 2010

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By Matthew Holt

There’s no doubt that despite my thoughts that Obama wouldn’t (and shouldn’t) have pushed health reform in 2009, it was a very big year for health care. Death panels, public options et al—one hundred thousand visits to THCB in August don’t lie.

So what should you look for next?

  1. The finish is the start: It looks like some version of the Senate bill will be a done deal by sometime late January. That means that there’s about two years of health care industry players figuring out what it all means. The biggest two questions are; what will the types of plan sold in the exchanges look like? (high deductible with some preventive care thrown in is most likely), and what will the cuts and changes in Medicare payment actually look like in practice? (More of the same or real re-alignment around some kind of bundling). All these changes need reactions from the incumbents to reorganize around the new revenue streams.

    2. Continue reading…

Where’s the magic with electronic medical records?

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By MICHAEL PAINTER, MDMPainter

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care: A National Study” by Himmelstein, et al. appeared in my Twitter stream. In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts. In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost. Shocking. Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data.

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted? As research by Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system. I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption.Continue reading…

Harvard Study Gets it Wrong on EHRs and Quality

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By GLENN LAFFEL MD, PhD

America’s hospitals are a triumph of modernity, stocked as they are with PET scanners, ECMO machines, and ICUs bedecked in eye-popping gadgetry.

They are also the most complex organizations ever created by man. The seemingly simple process of delivering a drug from the pharmacy to the bedside for example, typically involves a 30-step process executed by a half-dozen people on 3 floors. There are hundreds of ways it can fail.

It often does, and that’s just half the story. Each hospitalized patient requires a unique combination of services including lab tests, physical therapy, a discharge plan and so forth. Since a complex process must be executed to produce each service, the hospital becomes a job shop.

By contrast, the processes used to produce cars and silicon chips are relatively unfettered. That is why piston rods can be produced in batches with every item meeting specs to the micron, while hospital processes often feature error rates of 10-20%.

This explains why hospitals have struggled for decades to improve quality. It also explains why a study by Ashish Jha and colleagues at Harvard has shown that hospitals using electronic health records (EHRs) don’t have better quality.

Continue reading…

Measurables and Immeasurables

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“Our scientific age demands that we provide definitions, measurements, and statistics in order to be taken seriously. Yet most of the important things in life cannot be measured.” – Dennis Prager, 1948 – radio host, lecturer, columnist, ethicist

“My first goal for Intermountain is that anytime a physician or nurse says, ‘In my experience’ when they’re talking to a patient, they mean ‘In my measured experience.’ ”

– Brent James, MD, Chief Qualify Officer, Intermountain Healthcare, as quoted in “Dr. James Will Make It Better,” by David Leonhardt, New York Times Magazine, November 8, 2009

It all sounds simple enough. You measure everything you do. You gather claims data. You measure what works. You show measures of what works to doctors and nurses. You write protocols for doctors and nurses to follow what works. You pay more for what works. You pay less for what doesn’t work. You remove pay incentives that cause doctors to do more. You gather together doctors who lead organizations with track records for providing better care at lower costs at the White House.

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State of Health Care Quality: Some States Better Than Others

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Peggy O’Kane has been running the NCQA for longer than she might care to remember. NCQA is Peggy4an independent, non-profit organization whose mission is to improve the quality of health care everywhere, but it’s best known for creating the HEDIS measures that rate health insurer and provider performance. I’ve been a fan of Peggy since I met her in the mid-1990s. Today she shows she’s still fighting the good fight. This is her first contribution to THCB —Matthew Holt

Suppose you’re one of the 22 million Americans living with diabetes and you have to decide where you  want to live. Your choices: Providence, Rhode Island, or Houston, Texas.  Providence is pretty and you’d have easy access to lobster dinners and weekends at the Cape. But Houston is warmer in the winter and just a hop, skip and a jump from a weekend in Cancun.  A hard decision but you’re leaning toward Houston because, let’s face it, you hate shoveling snow!But then you take a look at the 13th annual State of Health Care Quality Report by the National Committee for Quality Assurance (plug alert: I run the place) and you find out the quality of care for diabetics is nearly 11 percentage points better in New England than it is in the South Central region of the U.S. and you begin to reconsider. In fact, you look at the newest data released October 22 and you find that the quality of care in the Texas region of the country is consistently the worst while care in New England is almost always the best.  Providence here I come!

Here’s the problem: Most people don’t have a choice of moving from Texas or Oklahoma or Alabama to Massachusetts, Connecticut or Rhode Island. They have to live with the health care system they have. For a diabetic, those 11 points can translate into more kidney problems, loss of vision, toe or foot amputations or, heaven forbid, a shorter lifespan.The thing is, it doesn’t have to be this way. True, care isn’t going to be identical in all parts of the country. And, true, the population of Dallas may have a lot more health problems than the people in Hartford. But 11 points is too big a gap to explain away with demographics.

Continue reading…

Docs Wash Hands Like Guys In Gas Station Bathroom

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Thursday was Global Handwashing Day

OK, a new study by the London School of Hygiene & Tropical Medicine did not directly compare how often someone washes their hands after using a gas station bathroom and how often your doctor washes his hands before examining you. But, being careful not to touch anything, we can do the math.

The School of Hygiene study just published in the American Journal of Public Health, placed electronic sensors in service station bathrooms along highways in Britain to see the way men and women responded to electronic reminders to wash their hands with soap and water.  After monitoring some quarter of a million people, they found that 32 percent of men and 64 percent of women washed their hands.

Most of the electronic messages caused some improvement in hand-washing, but the one that worked best was, “Is the person next to you washing with soap?” As one researcher told the BBC, “What other people think – what is deemed to be acceptable behavior – is probably a key determinant….It was interesting to see that, for men, the more people there were in the toilet, the more likely they were to wash their hands with soap.”

Which makes the average British male very much like U.S. doctors. As an article by Didet et al. in the Annals of Internal Medicine (and concluded, doctor hand-washing “was associated with the awareness of being observed, the belief of being a role model for other colleagues, a positive attitude toward hand hygiene after patient contact, and easy access to hand-rub solution.”

But at least British motorists aren’t stepping out of the gas station into a surgical gown. A multicenter study in the United States, published earlier this year by McGuckin and colleagues in the American Journal of Medical Quality, found that baseline compliance for following hand hygiene rules was just 26 percent in intensive care units and 36 percent in non-ICUs. After a 12-month “feedback intervention,” compliance increased to just 37 percent for ICUs – about the level of the average guy using a bathroom in a British gas station – and 51 percent for non-ICUs – still below the average female British bathroom user. (No word on whether female doctors washed their hands more than their male counterparts.)

The School of Hygiene study said that men responded best to messages of disgust, such as, “Soap it off or eat it later.” Meanwhile, the World Health Organization estimates that health care-associated infections affect as many as 1.7 million patients in the United States each year, cost $6.5 billion and contribute to more than 90,000 deaths annually.

Perhaps sinks in U.S. hospitals should consider electronic messages of their own, such as, “Soap me before I kill again.”

Michael L. Millenson is the president of Health Quality Advisors LLC and holds an adjunct appointment at Northwestern University’s Kellogg School of Management. He is the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age and, earlier in his career, was a Pulitzer Prize-nominated reporter for the Chicago Tribune.