THCB

Categories

Tag: Quality

QUALITY: Can a hospital CEO get us all to integrate (medicine, that is…)

• 7

This is pretty interesting. A fairly hard nosed hospital CEO, under it appears the tutelage of his new wife, gets into alternate and preventative medicine. 

Three years ago, Treuman Katz got some troubling news: At 60, he was on his way to becoming a diabetic. Katz, CEO of Children’s Hospital & Regional Medical Center at the time, could have relied on the region’s top specialists. Instead, the man who had spent nearly 40 years running two of the country’s pre-eminent hospitals reached out to a naturopathic doctor. He took herbal supplements, changed his diet, started yoga and hired a naturopathic trainer. Soon, his blood sugar dropped and he began to feel healthier than he had in years, he said.

Fair enough. But then he tries to integrate it with the care his institution delivers.

That opportunity came five years ago, when Katz and his medical staff
started to notice an intriguing trend: More than half of their patients
were using natural medicine but not telling their doctors. Therapies
ranged from herbal supplements to acupuncture.

So Katz organized a small group of physicians to visit Bastyr to
start connecting NDs — naturopathic doctors — and MDs, Molteni said.Brown-bag lunches with Bastyr naturopaths followed. The hospital put
together a group to study how herbs could affect drugs. It hired two
anesthesiologists/acupuncturists and will work with Bastyr to bring on
a chiropractor, a naturopathic doctor and a traditional
Chinese-medicine practitioner within the next year or two.

I live in a city with more than 70 yoga studios and probably more than 300 acupuncturists, so there is something going on in the alternate care movement that deserves some level of integration with tradition western care. This might be one approach that makes sense.

QUALITY/TECH: Bob Wachter on patient safety

• 1

Bob Wachter is probably the leading expert in the nation on medical errors and a great speaker.

He’s worried about the lack of budget for training, and that IT = Patient safety. But he does think that the IT/EMR movement is now tipping, especially as the disconnect between patient’s perception of being high-tech and what’s happening in the health care system is not tenable, and docs saying that they can’t do it is not credible even for the older docs

He talks a little bit about computer induced errors and problems. There’s a new literature replacing the Bates stuff about how great the Brigham’s system was, and now it’s all about how it’s going wrong.  It’s not a mistake to computerize but you need to go in with your eyes open. You need to think about the process improvements…including the easy ability to cut and paste H&T and continuing on mistakes. What happened when the computer goes down? As at Beth Israel Deaconess. And then in the example for Childrens’ Pittsburgh, does CPOE kill people? Well the chaos still goes on and CPOE clearly gets in the way in ICUs. The critiques of this study are that they "didn’t do it right" but that’s what an implementation looks like. Plus what looks good in the demo doesn’t work per se in your local community hospital. Or the experience of the Brigham is not transferable …unless your hospital also has a 1,300 strong IT department.

The Cedars Sinai story: They built their own and they built in some decision support. But the medical staff revolted. Too many alarms, reminders, too many screens, etc, etc. But not just that, also a story about control over medical care.  Cedars was exerting central control.

So the question is, who exerts control. He quotes Spiderman. "With great power comes great responsibility"  Now there are institutions that are going to have to wrestle with this problem, and if you push too hard the backlash is very tough.  get it implemented first, and do the control later…one little thing at a time.  It’s like the Right Stuff which changed the test pilot from being a cowboy pilot like Chuck Yeager to being a goody two shoes Astronaut like John Glenn….it got more boring, but mortality rates fell dramatically. So this shift is coming too, and will be a huge shift.

Add to this the emergency dislocation of medicine, such as late-night radiology reading in Bangalore. This means that the world gets wired and we start to figure out how to provide care very differently. eICU from VISICU is another reason, seeing a real time data stream and facilitating the care remotely. One of the most profound affect is going to de-tether the assay from its interpretation.

TECH/QUALITY: Leapfrog

• 7

I’m at a conference on patient safety…

Suzanne Delbanco is the CEO of the Leapfrog Group. This is the group which is where big employers get together to grouch about health care and ask the providers nicely to try to provide better care, cheaper, and suggest that they adopt some innovations like using computers–which of course get rebuffed. She thinks that "in this country we have a funny employer-based health insurance system".  So employers are moving to cost shifting, etc, etc, but they know that wont work.

So Leapfrog was started to try to improve the process, to make "leaps" in patient safety and quality. CPOE was the first not only because it was the gold standard for reducing errors but because it also required hospitals to put in the information systems that will enable process measurements. They’ve focused on inpatient setting, but are looking at outpatient eRx, lab tests, and care management prompts. Now as the base for Bridges to Excellence office link program.

They run their own online survey (voluntary and online) and license the data.

So how have they done? Well progress on CPOE has been slow. They think they’ve gone from 2% to 7%, and another 17% say they’re working on it.They are also creating a CPOE evaluation tool (something that HISTalk might want to get involved in)

She also asks is transparency enough? Well the AHRQ quality report showed improvement in nursing home care (15%) compared to only 3% in hospitals, because Medicare mandated reporting by nursing homes. Now CMS is quasi-mandating reporting by hospitals, so she expects that improvements will start showing up in hospital quality measures.

In addition P4P is getting closer to being standardized and less confusing, although not widespread…they are seeing more and more P4P, such as Bridges to Excellence. She’s also on the CCHIT committee that will be evaluating and later certifying products for the physician setting.

On the other hand I didn’t ask the nasty question which is given that
the employers have let their suppliers stick them with 15% annual
increases add infinitum why do they think that anyone is going to be
convinced by these efforts?

QUALITY: We spend how much on the NIH and how much on AHQR?

This is far, far too true.

Spending less money on better drugs and more on getting existing therapies to patients would save more lives. That’s the conclusion of a study published by a Virginia Commonwealth University family medicine and public health physician."For every dollar Congress gives the National Institutes of Health to develop blockbuster treatments, it spends only one penny to ensure that Americans actually receive them," said Steven Woolf, professor and director of research in VCU’s Department of Family Medicine and a member of the National Academy of Sciences’ Institute of Medicine. "This reflects, in part, a misperception that the improved drugs, procedures and the like will improve health outcomes, and that does not happen," he said.To illustrate, Woolf used a theoretical disease that claims 100,000 lives a year. If a drug is available that reduces the mortality rate from that disease by 20 percent, it has the potential to save 20,000 lives each year, he said. But if only 60 percent of eligible patients receive the drug, only 12,000 deaths will be averted. So closing the gap in care by making it available to 100 percent of eligible patients would save 8,000 additional lives, Woolf said.But to save the same number of lives by making a better drug and without closing the gap in care, i.e., delivering the better drug to only 60 percent of eligible patients, the drug’s lowering of mortality would have to be increased from 20 percent to 33 percent, he noted. Calling this the "break-even point," Woolf said that is an unrealistic goal for many treatments. In fact, the study showed that the billions invested in statins and anti-clotting drugs failed to reach the break-even point.

And we know that this is not just theoretical.

INTERNATIONAL/QUALITY: U.S., Canada heart-failure mortality compared

• 6

This one’s from last week, but well worth a quick look. A study in the Archives of Internal Medicine compared heart-failure mortality in the U.S. and Canada

Two findings emerged from a recent Archives of Internal Medicine report on heart-failure mortality rates. One affirms the notion that the U.S. is a leader in acute care, but the other finding offers evidence that there’s room for improvement in the management of chronic conditions.The report, which was released Nov. 28, compared 30-day and one-year mortality rates of American and Canadian heart-failure patients measured between 1998 and 2001. The findings: after risk standardization, the 28,521 U.S. Medicare beneficiaries studied had a lower 30-day mortality rate than the 8,180 similarly aged patients at hospitals in Ontario, Canada (8.9% vs. 10.7%), but one-year adjusted mortality rates were essentially the same (32.2% in the U.S. vs. 32.3% in Canada).

So in other words we spend a lot more here and there some short-term benefits, but soon enough the differences disappear (but of course the money is still gone!).  I was struck by this particularly because Vic Fuchs did a study back in the 1980s at Stanford hospital comparing the outcomes of patients admitted to the same hospital by the faculty versus community doctors. Compared to the community doctors the faculty doctors supplied more services and spend more money on patients with similar acuity (i.e. similarly sick patients). And in the short term their patients had better  results, but after several months outcomes were the same. When Fuchs talked to them with the results, both sets of physicians thought that their type of care (i.e. more intensive versus less intensive) was better for the patients.

The health economists, though, amongst us tend to believe that there’s precious little point paying a lot more money to keep very sick people alive slightly longer, when within a year they’re going to be as dead as the rest of them. And that appears to be the way it works in Canada too. Anyone really surprised?  Of course with the Dartmouth data we also know that the same variation is exactly the case between different parts of the US.

QUALITY/POLICY: Vince Kuraitis on Medicare DM

On Friday, November 4th, 10:00 AM – 10:45 AM Pacific (1:00 PM – 1:45 PM Eastern), Vince Kuraitis, Principal. Better Health Technologies and a leading Disease Management guru will be doing an audioconference of this presentation as part of Managed Care OnLine’s (MCOLs) Managing Health Care Costs Web Summit. I’ve seen an advance copy of his presentation and if you are interested in figuring out what  the heck is going on within the Medicare DM experiment that was called CCIP and is now called something else, I suggest that you sign up.

(If you don’t work for a corporation that can pay the freight but are still desperate to see it, Vince might be able to help, so email  me).

QUALITY: Job at DM company Lifemasters

So if you’re not quite as cynical as me about the future of disease management, LifeMasters is looking for a Product Development Manager in its South San Francisco offices. This is a position that works on the product team and is responsible for development of new products and features. The candidate must have insatiable curiosity about how things work and a desire to improve them.

It’s a stimulating, intellectually challenging environment in an industry-leading DM company that’s growing like gang busters. And you get to work with the ever-wonderful Mary Cain, my former IFTF colleague. If you’re interested, scroll down in this listing till you find it, and if you still think it’s you, email kwaxmanATlifemastersDOTcom

Do NOT email me!!

PHARMA/QUALITY/PHYSICIANS: Rational sense on opioid use for cancer sufferers, with reference to Kinsey and rationalism.

• 1

A very important THCB reader — one that I have to be nice to if I want to feature in the will, and you might guess that I’m a couple of wickets down already — has forwarded me this BMJ article on opioid use for cancer patients.

Last night I saw the movie Kinsey, which told the story of how Kinsey’s research on human sexuality in the 1940s and 1950s created great advancement in human understanding, and helped remove the weight of hundreds of years of damaging religious bigotry — yup into the 1930s married couples were taught that any non-missionary position sex (including using the mouth or the fingers) was wrong and unnatural. There’s a harrowing scene were his father eventually tells him that he was fitted with a strap to prevent masturbation. I thought of this in the context of opioids, because apart from certain lunatics on the Christian right, rational people agree that the behaviors imposed by society on sexual "deviants" — homosexuality was a jailable offense as recently as the 1950s –were both morally wrong and harmful to individuals and society as a whole. We needed science (and I know there’s a lot of criticism of Kinsey, M&J and Hite’s methods, but they approached the issue from a scientific not a moralistic perspective) to show us the truth in a rational dispassionate way.

The war on pain doctors and patients is being fought by a similar band of lunatic puritans as attacked (and still attack) Kinsey.  Only these moralistic jihadists have the full force of the Justice Department behind them and are clearly bending every commonsense understanding of justice and ethics to imprison and destroy anyone who holds a different, more humane view.

Of course the main problem here is that the puritan jihadists have equated opioid use for pain as some kind of great moral failing. Well the scientific view is succinctly and excellently put by a leading British physician:

Concerns about morphine: Morphine has long been feared by the general public and the medical profession. Underlying this fear is the mistaken belief that the potential for misuse of opioids is linked with their use as analgesics. Unfortunately, concerns about addiction, respiratory depression, and excessive sedation cause healthcare professionals to avoid using opioids or to use them in suboptimal doses. Clinical experience has shown that these fears are largely unfounded and that addiction is not likely if morphine is used to manage pain responsive to opioids in doses titrated to the degree of pain. Withdrawal symptoms indicate physical dependence and should not be confused with psychological dependence (addiction).

It’s mainstream educated work like this that needs to be broadcast widely, and all physicians and other scientists need to continue to trumpet this loudly. Don’t forget that the puritan jihadists want to take us back to their equivalent of Sharia law, and the real fight among civilizations is not between Christians and Muslims, it’s between the rationalists and the zealots. And if you think I’m overstating it let me  use this quote from the Guardian of a smattering of leading anti-Kinsey campaigners (yup, they really exist)

The religious right still fear and despise Kinsey and all his works. Check out some of the (apparently coordinated) responses to the new movie. "Kinsey’s proper place is with Nazi doctor Josef Mengele," says Robert Knight of Concerned Women for America, inadvertently showing us what he thinks of the Holocaust. Robert Peters of Morality in Media: "That’s part of Kinsey’s legacy: Aids, abortion, the high divorce rate, pornography." Focus on the Family’s film critic (they have a film critic?), Tom Neven, calls the movie "rank propaganda for the sexual revolution and the homosexual agenda". And Judith Reisman, who has waged a decades-long war against Kinsey’s memory, refers to "a legacy of massive venereal disease, broken hearts and broken souls".

And is it a Jihad?  Well the lunatics certainly think so:

A recent newsletter of the abstinence-education group Why know? compared the publication of “The Kinsey Report,” in 1948, to the attacks of September 11th, and labeled Kinseyism “fifty years of cultural terrorism.”

QUALITY: DM has been counting it wrong but Al Lewis sets it straight

• 2

Over the last year or so the DM listserv has been buzzing with the concept put about from Al Lewis, Ariel Linden, and Ian Duncan that to this point ROI for disease management programs has been calculated wrongly. But in an interview with Managed Care magazine Al explains how to get it right, and also predicts that this will help DM finally take off.

My cynicism has been detailed — and refuted — before in THCB, but at some point getting DM right will make sense. My fears of course revolve around problem that the the incentive for a insurer to get rid of a sick member is much greater than the incentive for them to manage that member well, and it’s a damn site easier to do the former.

assetto corsa mods