I won’t rant on about it, but the DOJ headed by theocratic fascist John Ashcroft has declared war on pain doctors. For much more take a look at the Pain Relief Network’s site. And the arrest, imprisonment and career destruction being meted out not just to “outlaw” doctors but those in the forefront of science on pain relief has a visceral effect on how pain is treated for patients across the board. For a gut-churning example of how much pain rational intelligent clinically-educated patients are forced to endure by the system, see this article on the treatment of “My Left Lung” by nurse and patient Richard Ferri.

But slowly the tide may be turning. In an article titled Must We Die In Pain? the radical commies at Forbes note that little progress has been made yet.

In 1995, a group of researchers funded by the Robert Wood Johnson Foundation published a shocking result in the Journal of the American Medical Association. At some of the nation’s top medical centers more than half of cancer patients passed away in serious, uncontrolled pain. But guidelines from the World Health Organization indicate that 85% to 90% of cancer patients could have their pain controlled by oral medications. It seemed like a solvable problem. The Wood Johnson Foundation and the Soros Foundation were among the groups that worked on trying to improve the care of the dying. (The Soros Foundation’s Project on Death in America spent $45 million on improving end-of-life care.) What do we have to show for it? Patients still die in pain. A recent study by Joan Teno at Brown University found that of patients in nursing homes with excruciating pain, 42% were still suffering after a second assessment.

But,(as certain politicians might say), hope is on the way. First, there is greater awareness among clinicians of this issue than there was some years ago, and the realization that pain patients are almost always not the same as recreational opiod addicts. In fact a relatively dispassionate reading of the data suggests that almost all deaths from Oxycontin abuse come in conjunction with other forms of substance abuse and have nothing to do with pain management patients. Second, there is better awareness among physicians of alternatives, especially for the dying:

Doctors don’t always know about alternatives to narcotics. Raymond Gaeta, director of the Stanford Pain Management Service points out that a whole host of treatments exist. One option is anti-epilepsy drugs such as Neurontin from Pfizer (Note: which as described elsewhere in TCHB is dramatically growing in use) and Topamax from Johnson & Johnson, which can ease the pain of nerves damaged by chemotherapy. When these medicines don’t work, there are local anesthetics, and drugs delivered directly into the spine by pumps such as those made by Medtronic. These pumps are expensive–costing some $10,000 per patient–but Gaeta thinks they’re worth it, even for patients who only have a month to live. Doctors also can simply surgically destroy nerves, preventing the patient from feeling any pain.

Third, much of the fuss about pain and the DEA and DOJ’s draconian assaults on pain doctors have to do with Oxycontin, and the ability of addicts to somehow break down its slow release mechanism to use it for a heroin-like high. At least one company, Pain Therapeutics, has two drugs in clinical trials designed to deliver Oxycontin-like pain relief without either the high or the addictive side effects. One is designed to reduce the addictive qualities of the opiate, and the other is designed to prevent abusers from breaking down the slow release mechanism. (Disclosure: I own stock in Pain Therapeutics. Do your own DD but obviously I think it’s a winner) Whether or not these drugs work, there is clearly a market for making a safe and effective, non-addictive pain killer, that will hopefully send Ashcroft’s goons into retirement–although hopefully he’ll beat them to it in January.

Finally the DEA and several consultants from academic medicine came up with some pain medication guidelines, that hopefully will make physicians more confident in their ability to use opiates without feat of arrest and professional suicide. Let’s hope that the “enforcement” side of the agency is kept on a shorter leash now that the “drug” side has created these guidelines.

Navigate your way over to DB’s Medical Rants to read Robert Centor on the VA doing better than managed care plans in a study of care for diabetics. Here’s the AP Version and the study abstract. Essentially back in 1998-9 the VA’s diabetics got statistically better quality care than a matched selection of patients in managed care plans. This tends to make me believe that there’s still not that much care-management going on in the general “commercial” population.

Now the “managed care” population is not a homogeneous blob. You can’t tell which plans these patients were in from the article, but some were in Hawaii and Northern California (where Kaiser is 50% & 30% of the whole market respectively) while others were in Indiana, which basically never had any managed care. So my suspicion is that the rates of care is a factor more of the delivery environment than the type of insurance coverage. But nonetheless, hats off to the VA for this care. (Right, that’s enough praise for that evil socialized medicine….)

However, some of the uglier traits of “Managed Care” (such as utilization review and physician hassling) which were dying out in the late 1990s (the time analyzed in the study) are apparently making a slight comeback, according to this recent HSC report in Health Affairs. There’s even the odd case of care denial that makes me fell that we’re back in 1996, such as Cigna recently doing a flip-flop after denying payment for an experimental procedure. I’m almost expecting $93m judgments against Healthnet with Mailk Hassan making cameo appearances in stretch limos and Time magazine.

I just get the vague sense (based only on anecdotal observation) that the DSM/care management trend is becoming slightly more important again for health plans. But it’s nowhere near as important as getting rid of the bad risks up front, as Aetna has shown its shareholders. Is there a real trend towards care management from health plans? Or is it just medical directors talking shop over at the DM Forum? Comments on a postcard please!

Two amazing articles in the NY Times in recent days show that–as John Mattison from Kaiser told me in 1996–although we know what to do we don’t know how to do it. First off a study of a PBM’s database containing all prescriptions written in 1999 for 765,423 patients over 65 found that 21 percent of the patients had at least one drug on a list of drugs potentially dangerous for seniors, and that half those prescriptions were for drugs considered to have the potential for serious adverse effects. (Here’s the California Healthline link with more details).Then we come to Thursday’s NY Times article about the long-term failure of what appeared to be a successful disease management project in Washington state–again because the incentives were in the wrong place. I think that the way Medicare (and other insurers) set up their incentives is mostly to blame. But The Industry Veteran has a more familiar foe in his sights:

Now believe it or not, fixing this isn’t that hard. In the bad old days of HMOs–the early 1990s–Friendly Hills medical group and others in southern California would get all their senior patients into a brown bag lunch, tell them to bring all the pills they were on, and then pharmacists would basically go around the getting the patients off all the drugs they shouldn’t have been on at all or ones that counteracted each other. And this was prior to computerized pharmacy records! Why hasn’t this spread (other than Caremark/Medpartners buying and destroying Friendly Hills in the mid-1990s)? Well Medicare doesn’t reward that activity, but it does reward the multiple visits to doctors to get multiple scripts. And even though doctors know that this is both bad medicine and a safety risk, there’s been no national movement to do much about it.

The subdued, temperate mice in healthcare analysis (I think he means me!–Ed) consider me entirely too hostile because I refer to physicians as Mafiosi and whores, but here’s an article from Wednesday’s NY Times that should elicit temperate responses only from corpses and theocratic fascists. Written by Gina Kolata, a groupie for anything in a lab coat, the article discusses a pilot program, called a "shared care plan," that Medicare ran in Washington state among people with concomitant diabetes and CHF. The program has two components: greater access to medical records via IT and the use of non-physician, clinical care specialists.

To paraphrase the gist of the article, physicians, patients and their families have access to a patient’s computerized medical records. This allows patients to note changes in their reactions to medications. Every physician in the geographic area can access the updated medical records. Then the clinical care specialists serve as personal assistants to severely ill patients, going with them to doctors’ offices, being available by cellphone to answer questions, and teaching them to manage their diseases. The program has reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels, those with congestive heart failure have remained stable instead of getting worse, and third-party payers such as Medicare save money. Therein lies the rub. Participating in the program costs each doctor in the group $500 a month over four years for the electronic medical record system while other innovations, such as group office visits and e-mailing with patients, receive poor reimbursement, if any. As a result, physicians say they will refuse to participate in the program after the pilot ends.

Hell, we don’t need John Kerry to replace George Bush, we need Harry Truman to draft these Mafiosi physicians into the Army. Then they’ll comply!

As you know as a subdued temperate mouse I’m a sucker for those nice doctors but on the other hand, doing demonstrably the wrong thing because it pays better doesn’t appear in in the version of the Hippocratic oath I remember. So this is a clear case where Congress needs to step up, and in a bi-partisan fashion institute both pay-for-performance for Medicare to get us away from the FFS treadmill and hold hearings to shame the AMA and the rest of the "Mafiosi" into doing the right thing, right away. It’s been long enough.

Writing an Op-Ed in USA Today, Michael Millenson says that making a national error reporting system voluntary won’t work. The Senate voted 98-0 to create such a system last week and USA Today had an editorial saying that it was a good idea, but should have gone further. In some ways that such articles appear in the mainstream press shows the great progress since the IOM issued the To Err is Human report, given organized medicine’s ability over the previous century to quiet the incipient debate on the medical error and quality topic, (as detailed by Millenson in the wonderful Demanding Medical Excellence). But the IOM set out a goal of a reduction in errors of 50% in five years. Well the report was issued 5 years ago next month and no one is pretending that target has been reached (outside of LDS hospital in Salt Lake City, scroll down here to the June 10 entry for more on that)Here’s what Millenson said yesterday:

While voluntarism is valuable, it has been five years since a landmark IOM report made patient safety a public scandal. During that time, doctors and hospitals have not voluntarily organized to stop the preventable deaths and injuries of hundreds of thousands of patients with anything close to the energy used to battle malpractice awards worth hundreds of thousands of dollars.

Doctors and hospital managers are not venal and uncaring. In fact, many care so much that they find it too painful to face up to the commonplace nature of errors. As a result, doctors routinely protest that the patient-safety issue is overblown. I’ve seen it firsthand hundreds of times. If you really believe in systemic change, you have to be willing to shock a lethargic system into abandoning the status quo.

The way to do that is with the mandatory reporting of serious errors. In Minnesota, for example, progressive hospitals supported the mandatory reporting and analysis of 27 serious events, along with appropriate confidentiality and legal ”safe harbor” provisions. Moreover, errors are tabulated and made public each year. Across the U.S., a few courageous hospitals even involve patient representatives in error-prevention panels.

No member of Congress would think of making airline-crash prevention voluntary. Protecting the sick and the vulnerable among us is surely at least as important.

The rhetoric continues to be turned up in the "debate" about malpractice. This LA Times article suggests that a RAND study found that California’s $250,000 cap on non-economic damages in pain and suffering awards dramatically cuts the amount that juries want to give to seriously wronged patients. Incidentally juries are not told about the cap, so when they come back with a number it is reduced by the judge. Perhaps if more juries knew about that the awards for "economic" losses which are not capped would be much, much higher. In any event, expect far more cases, like the one reported via Michael Millenson’s talk about the woman who had both breasts wrongly removed due to a pathology error, turning up in the press.

Politically, though, this all seems to be at a dead end. If the current House and Senate can’t get anything done…well they’re hardly likely to become more Republican after the next election, are they? And when the Presidency changes hands next year, a real-to-god trial lawyer will be the vice-President (cue angry emails from my few Republican readers). Anyway, my point is that there are not the votes in the Senate to do anything about it, and I don’t hear even too many AMA members or Republicans wanting to abolish the Senate (although some on the left do!).

So perhaps the answer is to try something radically different. Taking malpractice out of the courts, and into expert based truly neutral arbitration. Having firm rules of adherence to evidence based medicine. Admitting medical errors, and compensating for them fairly from a national fund. Trying to improve the practice of medicine rather than the practice of defensive medicine. I don’t know the full extent of the answer, although there are many reasonable proposals out there. I do know that the current insistence on a California-model nationwide is not going to fundamentally solve the problem, and isn’t going to happen. So we might as well go for a big goal that makes a difference rather than failing to achieve a small one that doesn’t.

A couple of weeks back there was an interesting signal that something that’s been debated by policy wonks for some time may be impinging beyond the fringes of the real world of health care. Jack Bovender, CEO of HCA the biggest for-profit hospital chain called for Congress to create standards for pay-for-performance programs. Meanwhile the Leapfrog Group, the employer group that’s been pushing P4P, has created a web site to help y’all keep up with the multiple P4P programs out there. (Here’s the press release).

So it seems that these programs are getting enough attention outside the sideshow health care worlds of California and Massachusetts, that HCA–which doesn’t have any facilities in those states–thinks that it needs someone to regulate and standardize the myriad of programs that, as a major provider, it’s going to have to deal with. In general I’m a fan of standardization in health care. The Dartmouth folks have shown that there’s far too little standardization of care delivery, and P4P programs are in some ways intended to reduce that practice variation. However when we hear calls for standardizing the process and demands for Congressional oversight, we should be very cautious. Firstly, P4P is very new. We don’t really know what works and Medicare (by far the most influential national payer) has yet to start its much vaunted demonstration projects in P4P. So trying to regulate the "answer" is way premature. Secondly, when you hear of a big player like HCA wanting regulation, that usually means that it believes it can do better influencing (or taking advantage of) the regulators than it can working with payers in the open market. And, let’s face it, HCA’s track record in that arena is not exactly full of sweetness, light and innocence.

The answer, is of course, no-one. And this interesting web site Factcheck.org, a non-partisan organization like the Center for Public Integrity hated equally by everyone, has an article about Bush’s use of Mark McLellan’s research which said that some 8-10% of HC costs were caused by defensive medicine,. It says something I didn’t know which is that the CBO looked into the research and couldn’t duplicate it. But that’s not the real issue. The real question is when those "defensive" tests and procedures were ordered, did the doctors and providers get paid? The answer is of course yes. Which means that getting rid of defensive medicine will mean reducing providers incomes. Is that what the AMA really wants?

Yesterday I ended a piece on medical safety with a reference to a well known British agony auntie advice columnist who will not go into hospital unless she’s at the point of death, primarily because of the lack of training (and lack of professionalism) of the staff she saw in her last visit where she contracted a severe nosocomial infection. One issue that she included was the relative lack of RNs who were involved in patient contact.

Another issue, detailed well in this article from March 2004, has been the impact on patient safety of overwork for nurses. The story cites a malpractice case where 2 nurses had over 40 patients to look after, and at least one terrible diagnosis fell through the cracks to terrible effect for that patient’s future. Consequently several states, notably California, have mandated nurse to patient ratios (usually 1 to 6), and the initial news seems to be that it is improving patient care. However, a new article by the Univ of Pennsylvania team (lead author is Ann Rogers, but nursing staffing guru Linda Aitken is a co-author) suggests that increased work weeks, increased shift lengths and unexpected but forced overtime is also bad for patient care and increases error rates. As the article is behind Health Affairs’ fire wall, I’ve quoted a chunk of their findings and recommendations:

"Our analysis showed that work duration, overtime, and number of hours worked per week had significant effects on errors. The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting of 12.5 hours or more (odds ratio =3.29, p =.001). Working overtime increased the odds of making at least one error, regardless of how long the shift was originally scheduled (OR = 2.06, p = .0005). Our data also suggest that there is a trend for increasing risks when nurses work overtime after longer shifts (OR = 1.34, 1.53, and 3.26 for scheduled eight-hour, eight-to-twelve-hour, and twelve-hour shifts, respectively), with the risks being significantly elevated for overtime following a twelve-hour shift (p = .005). Although the effects of working prolonged shifts were clearly associated with errors, there was no interaction between scheduled shift duration and overtime (p = .17). Finally, working more than forty hours per week and more than fifty hours per week significantly increased the risk of making an error. Results were somewhat similar for near errors."

The article concludes with a recommendation, which is similar to that made by the IOM last year:

"Hospital staff nurses’ long hours may have adverse effects on patient care; we found that both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours. Because more than three-fourths of the shifts scheduled for twelve hours exceeded that time frame, routine use of twelve-hour shifts should be curtailed, and overtime–especially that associated with twelve-hour shifts–should be eliminated".

But there is a huge YABBUT behind all these numbers, and that YABBUT is the severe shortage of nurses (and allied staff) in the US.

The average age of a working RN is 43 and by 2010 it will be pushing 50. Admission to nursing schools is slightly up but the number of individuals sitting for the nursing exam is flat, and far too few new nurses are coming into the workforce. Increased demand based on the aging of the population (the 85+ group is doubling between 2000 and 2010, and of course the baby boomers start turning 65 in 2010) means additional demand for health care services. More, sicker patients plus fewer nurses to care for them means this problem will get worse, so the likelihood is more rather than fewer medical errors in the future. This is all well captured in the 2002 JCAHO report, Health care at the Crossroads.

126,000 nursing positions are currently unfilled in hospitals across the country. Some estimates are that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed. Turnover rates are at about 20% a year, and it costs nearly an annual salary to replace a nurse.

This is probably the biggest single problem facing hospitals today. So in the words of Valdimir Ilyitch, What is to be done? There seem to be two main strategies. The first is to buy in talent from abroad. This has worked relatively well for physicians–roughly 20% of new residents each year are foreign medical graduates (who tend to stay here). This may not exactly be good news for other countries, many of whom already have bigger nursing shortages than the US. For instance the Pasadena Star-News reports on importing nurses from Mexico, while nurses are being recruited from the Philippines, China and India. While this is all at some cost to the medical care of the people in those countries, as an immigrant myself I would never blame any individual for coming to the US to try to do better for themselves than they can at home. And of course the money sent home to their families often means that one nurse is supporting many people.

The second solution is to replace (the lack of) nurses with technology. Much of the recent hospital investment in IT is moving towards attempting to change the process of a nurse’s workflow. Too much time is spent recording patient information and fetching supplies, rather than directly delivering patient care. If IT systems can directly capture information from medical devices (i.e. blood pressure, pulse, etc) then nurses could spend less time recording that in the chart. If robots can bring supplies direct to the bedside then nurses won’t need to go fetch them and could stay with their patients. Even something as simple as the soon-to-be ubiquitous Vocera "no-hands" communications badge can save nurses’ time from answering the phones and returning pages.

Nonetheless, the nursing shortage is a real challenge for American healthcare (I’m not so convinced about the "physician shortage" by the way!). And it’s a challenge that has a serious negative impact on the quality of care being delivered. However, I have some confidence that in 10 years time, the use of technology will improve the job of the nurse which will eventually cause more Americans to choose nursing as a career, and finding it a rewarding one psychically as well as financially. I hope I’m right, otherwise it will be grim to be old and sick in 20 years time if you can’t afford your own private nurse.

UPDATE: My cautious optimism that IT would help guide us out of the nursing shortage mess did not sit well with The Industry Veteran, who leaves his lair of pharma exclusivity to talk about nursing. But don’t worry, he stays in character with his remarks about doctors! So in an attempt to keep my email box from overflowing with his MD admirers, I’ve hidden his comments in this update!

As far as the nursing shortage, so what else is new? My memory of this subject goes back to the 1950s, and even then, the lack of good nurses was considered a major obstacle to quality care in hospitals. Nurses’ hours are too long, performance suffers, enrollment in nursing programs fails to keep pace, yaddada, yaddada. I must say, Matthew, I don’t share your optimism that more IT will substantially improve the situation. More IT can help, but so can good shoes, meditation, chair massages and a hundred other measures. To extend your analogy, when Comrade Vladimir asked how we might transform the plaintive cry, "What am I to do," into the search for concerted action ("What is to be done?"), he specifically disdained tinkering around the edges and adopting increments that perpetuate the alienating system.Hospitals have always appeared to me as the most caste-ridden social organizations in the country. At the top sits a small group of physicians and senior administrators who earn large incomes and receive extraordinary deference. Everyone else works undesirable hours under problematic conditions, receiving mediocre compensation for jobs that require high skills and induce substantial stress. Want to get more and better nurses, lab techs, radiology techs and the rest? Well if your universal panacea is IT, my universal villains are the f

I saw Michael Millenson doing Grand Rounds at UCSF last week. Michael, who has been mentioned in THCB a number of times, is a former journalist who has become something of a "bete noir" to organized medicine–or at least would be if they paid him any attention. While the AMA debates not offering care to trial lawyers, Millenson continues to point out the general "Silence" of leading medical organizations on the medical safety issue. The case he discussed at the UCSF Grand Rounds concerned a woman who’d had a double mastectomy for breast cancer that was later found to be a case of wrong identity on the pathology slides. The case was used by trial lawyers responding to Bush’s attacks on them over malpractice caps. Of course the AMA and its political allies have plenty of other human interest stories of counties where there are no obstetricians/brain surgeons/pediatricians because of the cost of malpractice insurance.

However, this fight between the lawyers and the doctors continues to miss the point, which is that we are a long way from achieving widespread use of evidence-based medicine. One little thing that might help is the "signing" of body parts by the surgeon prior to surgery, now as the Washington Post reports it is recommended as standard. I recall that before knee surgery in California at Stanford Hospitals in 1996 I wrote "Not This One" in marker pen on my healthy knee, and that got the admitting nurse very annoyed. At least the medical error debate is now in the open.

What’s not so in the open is the in-hospital infection issue. Millenson suggested last week that a nosocomial infection during on of Cheney’s heart procedures, or (my preference) perhaps during Ashcroft’s recent stay in hospital, would really put that issue on the front burner. (They could of course have a complete and full recovery afterwards!) Maybe not, but he found for me a really vicious example in the UK, where the medical safety debate has been even slower to develop than over here. This one concerns Claire Rayner, who is the British equivalent of Ann Landers. In this interview she hammers on the issue of infections caused by sloppy hygiene in hospitals. Take a read, And before you say it couldn’t happen here, be assured that it is happening here too — unless the IOM is making it all up.

Claire Rayner ascribes the problem to a decrease in standards of nursing care, directly associated with an increase in the number of less-well trained people dealing directly with patients. Interestingly enough Linda Aitken’s academic work has shown that there is a relationship in quality of care and outcomes based on the overall level of nurses’ education in a hospital staff. So Rayner may be on to something there. In any event, the more known about this issue, the better, and whatever Newt Gingrich and anyone named Kennedy say, IT is not a guaranteed standalone fix here. We need a system change.

In Washington state a doctor wants a fellow doctor suspended over malpractice testimony. Matt Quinn (again endearing himself to my physician readers, and now getting THCB on the California Correctional Officers Association hit list too) comments:

More intra-physician contentiousness regarding the malpractice issue with some advocating reprisals on docs who serve as expert witnesses against other docs… I thought that was limited to cops and prison guards!

While I’m sure that there are plenty of docs who are more than willing to say just about anything on the stand for a buck, wouldn’t having (either or both) institutionally agreed-upon care standards (by which to validate testimony) and quality ratings for docs make things much clearer for juries?

Again, this speaks to the state of the medical profession… and the AMA and other institutional organizations should step up to take the megaphone away from those who act like children…