Over at DB’s Medical Rants Robert has responded  to my gentle chiding and has written a nice piece regarding what’s wrong (in his view) with Wampum’s piece on malpractice.  (Note that he got up at 4 am to write it too! Who’d be an intensive internist?)

He’s also alerted me (and you) to a very interesting report about how doctors changed their behavior after the results of the two big trials on HRT and Alpha Blockers in the last couple of years. (Reuters release here but both full articles are unusually available for free from JAMA via my earlier links). The findings suggest that doctors do indeed respond in their prescribing habits to the latest evidence, particularly if the results of the trial are blared all over the press. This just makes the whole conversation over evidence based medicine more and more confusing.  How come doctors change practice on a dime over the HRT study but take years and years to apply some of the best practices elsewhere . . . . . I think Robert’s deliberately trying to make my future article about this harder to write!

The IOM just held a two day meeting to follow up on the 2001 report on Crossing the Chasm, which focused on the quality of chronic care management. This meeting focused on how to make real improvements in the areas of Asthma, Depression, Diabetes, Heart Failure and Pain Control. (I presume that no one from the DEA was there to discuss how locking up doctors improves pain control). Don Berwick was there and gave what sounds a pretty raucous speech about how we’re wasting our money in the health system.  If you haven’t read his speech called Escape Fire, then take a few minutes and do so.

Stephen Schoenbaum and Randall Bobjerg, from the Commonwealth Fund and the Urban Institute respectively, probably just got themselves crossed off the AMA’s Christmas card list by publishing  this article in the Annals of Internal Medicine.  They suggest that doctors are paying too much attention to malpractice and not enough to actually improving patient safety.  In case you missed the point, Schoenbaum, an ex-Exec at Harvard Community Health Plan, one of the "good guys" HMOs is quoted in this interview as saying "All the discussion is about how do we minimize the impact of the suits rather than how do we minimize the number of suits". He also points out that certain groups of physicians, notably anesthesiologists,  have improved their patient safety activities over time leading to the question of why other specialists have not.

I’m going to waffle as to whether greater efforts by specialists to improve patient safety would be immediately effective, given my fuzzy position on whether evidence based medicine is easily-attainable in the real world (see yesterday’s post on appendectomy failure rates).  But it is fair to say that if some of the energy physicians spend on malpractice reform was redirected towards patient safety issues, we’d all be better off.

I am determined to get back to the conversation on evidence based medicine that I was having with Robert Cantor over at Medical Rants before the holidays. Sadly I’m too gummed up with other work to finish the thoughtful response his last reply to me deserves–although I have subsequently interviewed Michael Millenson, the bete noir of the EBM-deniers (if that’s a term!), who’s last piece The Silence took a pretty hard line with the IOM for not being as aggressive as it should be on the topic.  More to come on that later.

But I remind you that I started this by discussing why evidence-based medicine was so hard to achieve in real world  practice.  This balanced article from the Boston Globe shows that big city hospitals which do lots of procedures on kids do better on reducing the false positive rate for pediatric appendectomies than lower volume hospitals. It seems that it’s pretty hard to get the mistake rate of the big city med centers (still up at around 4.8%) at the local hospital where they don’t see so many and have twice the error rate. The key point in the Pediatrics abstract that’s not in the write up for the lay reader is that two thirds of these pediatric appendectomies are done at the lower volume hospitals, and therefore have the worse results. Yet how many parents want to drive an extra hour or so to a distant hospital when their child is in pain? Does the "centers of excellence" concept make sense for this relatively trivial level of surgery? Is an 8% error level acceptable when the cost is more likely to be financial than medical?  It’s still a tough subject. 

I shall vent later mostly about information use, and this study provides useful information on how we should be tackling this type of procedure.  But it’s a bigger system change to move this type of surgery than to get all the transplants, say,  to high-volume physicians.

This post is tangentially related to the back and forth I’m having with DB’s Medical Rants about evidence-based medicine. I owe DB a follow up to his post in which I will (hopefully) explain that capturing information about medical care and using it to improve said care is possible and will become more widespread. However, that post has to wait a day or so.  In the meantime there are some interesting reports out that impact on how drugs get used and why practicing the best evidence-based medicine is so difficult (but not impossible!). This was, if you remember, my earlier notion before I got forced into defending the concept of EBM–a defense I will take up again very soon!

First, there’s been a new study out from Express Scripts the PBM which last month put out a study showing that patients were being prescribed Cox-2 inhibitors like Celebrex, even though they should have made do with NSAIDS or ibuprofen. In their latest study the same team at Express Scripts looked at the combined use of Cox-2 Inhibitors with PPIs (like Prilosec). The theory is that Cox-2 inhibitors are better for the GI tract than NSAIDs, so that people getting Cox-2’s should be using fewer PPIs than those getting simple NSAIDs. In fact the study found:

. . . .many COX-2 prescribing physicians actually continued co-prescribing gastroprotective drugs like proton pump inhibitors or H(2) receptor antagonists …..gastroprotective drug use was actually higher for COX-2 patients than for those taking a traditional NSAID – by a margin of 20% vs. 18%.

And that’s not quite all, another Express Scripts study from the team lead by Cox, too (sorry, but I had to get that in somewhere!), found that the use of PPIs to reduce death by ulcers was not in the least cost-effective.

Forbes, a magazine which spends much of its time promoting the pharma industry, actually got so interested in this that they ran an article saying that it costs $150,000 To Prevent An Ulcer Death. Why is this happening?  Well physicians prescribe based in part on detailing and patient demand driven by DTC and Internet advertising–to quote a recent survey-based study on the impact of the patient-physician relationship in the Internet age

So in this half of the equation we’ve got doctors prescribing drugs they shouldn’t really be prescribing for a variety of reasons that don’t have much to do with following the best evidence-based medicine.  Meanwhile on the other side of the relationship there’s a new set of numbers out from Harris and BCG showing that, as we always knew, non-compliance in pharmaceutical regimens is rife.  And it’s rife for a variety of reasons.  Why didn’t patients take the pill the doctor prescribed?

BCG’s spin on this is that it’s the patients’ fault. But why would you take a drug if you couldn’t afford it or if it made you sick, and why would you trust your doctor over yourself? So there’s a combination of factors here that require education, communication and financial support for patients as well as doctors.

So my conclusion is that as there’s still lots of work to do in figuring out how to do a seemingly simple thing like getting patients to take their pills.  And there’s an equal amount of work in getting doctors to prescribe them the right pills. That’s if we can decide what the right pill is for the right patient, which as is common knowledge, we can’t.

Damn, I just realized that I forgot to take my one new and daily med yesterday!

I’m involved in a whole scad of research at the moment about why American medical care isn’t working as well as it could.  Obviously there are many many factors involved, but one of them is the general problem that, in the spirit of the Defense secretary, the "things we know we know, we don’t know" how to do in practice.  Or as it was said much more clearly to me 7 years ago by John Mattison, IT guru at Kaiser, "we know what to do, but we don’t know how to do it". The subject of course is how to implement best medical practices, otherwise know as evidence-based medicine.

Well I’ve come across two very interesting articles from the UK, where as I pointed out the other day, the government actually cares enough about improving the health care system that it’s spending money to make it better and encouraging things like best practice dissemination. But even there implementing evidence-based medicine is very hard.

Why so?  Well the BMJ had a study in 2001 where they actually got several GPs to open up and talk about cases in which they had knowingly done the "wrong" things; in other words not followed the guidelines, in this case how to deal with patients with severe hypertension. 

Of course, it’s not as simple as you might think.  The GPs tended to believe that they had to deal with the whole patient, while the specialists (consultant in Brit speak) only had to deal with their cardiology issues.  It took a combination of patience and conning to get patients to try something different, and even after using these skills patients frequently didn’t want to know about the "best" treatment:

Implementation was influenced by the relationships that doctors developed with their patients. "Even if the evidence was extremely good," one general practitioner said, "most of us would only ever interpret it in the context of the patient." Perceived patient characteristics could have a positive or negative effect on implementation. "Of course, if they’re the sort who always want the specialist, then you follow their [the specialist’s] advice." Another explained, " I think you have to judge how people feel about it. I try to get patients to reveal to me where they lie in the game . . . from I want it mate to I don’t want to know nothing about it doc . . . I make tremendous judgments."

However, there is also the all too human side of interpreting evidence in terms of what the individual has experienced. Several comments were of the type that suggested that personal experience outweighed the data:

Accidents, mishaps, or spectacular clinical successes have a direct influence on subsequent practice. Commenting again on anticoagulation in atrial fibrillation, a participant exclaimed, "I’m back on it." This doctor had previously been uneasy about anticoagulating patients in atrial fibrillation but had recently seen one of his patients who was not given warfarin have a cerebrovascular event……..One doctor summed up this view. thus: "We are influenced at least as much, if not more, by the experiences of individual patients as we are by the evidence."

Meanwhile, despite the fact that health administrators have been pushing the use of guidelines and those GPs thought that specialists were using them, guidelines are not uniformly followed by consultants either. A different study which surveyed several hundred doctors and health officials on their use of guidelines found that:

There was little variation in the belief that the evidence-based guidance was of "good quality", but respondents from the health authorities (87%) were significantly more likely than either hospital consultants (52%) or GPs (57%) to perceive that any of the specified evidence-based guidance had influenced a change of practice.

My conclusion is that no evidence-based guideline will be perfectly applied. Some don’t take into account the human situation of the patient. Meanwhile physicians will find it very hard to do something that their experience tells them is wrong–no matter what the data says.

But of course in the US this is more or less moot, as we don’t have the data.

UPDATE: Over at DB’s Medical Rants, Robert Centor has an excellent post about this post and links to some of his earlier posts and other articles about this issue. He makes some glaringly obvious but all too often overlooked points about how technology/innovation gets adopted and has a very nice version of the classic "S" curve, as applied to medical adoption.  He’s also been working directly in the field for several years so I defer to him if he says I’ve "partially" nailed it–better than hitting my thumb, I suppose! Robert’s point is that plenty of work is being done in the US on evidence-based medicine, and that it is changing practice patterns. He therefore quibbles with me when I say that we "don’t have the data".  My response is that the "data" we have is the numerous studies that he and others have been involved in about what is the best way to treat condition X, Y or Z. In other words we have the "we know what to do" part–it’s the "how to do it" part that’s missing

I, of course, know that evidence based medicine is studied intensely in the US, as is health technology assessment, health services research and regional health planning.  Unfortunately like those other worthy disciplines (and I have a degree in one of them!) its study stays mostly in academia and makes precious little impact in general patterns of medical practice. The "data" we do not have and the data that I was (obtusely) referring to earlier in this post was the data directly gathered about how physicians actually practice from their records. It’s the lack of accessible electronic records which stops us accurately understanding (and then managing) how practice works in real life/real time.  Several medical directors of leading medical groups have been telling me for years that they don’t have an accurate picture of what their MDs are doing because they can only get statistical glimpses of their practice patterns at the end of each month.  Of course the vast majority of physicians do not practice in groups that have this kind of collegial monitoring and end up having their performance assessed only by adversarial health plans, trial lawyers, the occasional academic study, or most likely not at all. Given that you cannot assess performance when the data is locked up in paper charts, I believe I’m justified in saying that on balance we "don’t have the data". 

Of course if you look at the statistical glimpses that Wennberg and his colleagues at Dartmouth have extracted mostly from Medicare claims data, the wide regional variations in practice show that evidence-based medicine can not logically be being applied nationwide. Otherwise you wouldn’t find three times the amount of surgery going on for the same condition in Denver than you see in Salt Lake City.  Part of the reason behind the UK’s investment in electronic records is the desire to get at the information source that is the everyday recording of clinical activity. If it’s achieved that huge data set will be used to both monitor medical care and assess what is the best evidence-based practice from huge data sets, rather than from chart abstracted studies done later.  And eventually the one (practice) will be monitored against the other (evidence based guidelines)–something not all doctors will welcome.

In the US the lack of electronic records prevents this, and as I’ve explained in this post, we don’t seem to be in too much of a hurry to change that situation. And even if we did, then all the problems of actually changing practice patterns that Robert and I have been discussing still have to be overcome.

In my background for the post last week on paying for Quality, I came across some of the more recent work by Michael Millenson, who wrote the great Demanding Medical Excellence. Millenson is not only a smart guy who tells a good story but he’s been a professional journalist for a major daily and a consultant for a major benefits firm.  So his explanation of why the IOM’s To Err is Human report hit such a nerve is well worth reading.  Partly it was the culmination of a slow groundswell of news and opinions from across the nation, both from reporters and consumers, and even a few doctors. But just as important was the fact that the IOM used human interest stories which were easy for journalists to latch onto and reproduce and also it was released on a slow news day.  Scary but true, that’s how things get to be a big deal in America. You can read Millenson’s article Pushing the profession: how the news media turned patient safety into a priority here.

One of the best books on health care ever, second only to Paul Starr’s The Social Transformation of American Medicine is Michael Millenson’s Demanding Medical Excellence. In his tracing of the history of health care quality, Millenson demonstrated how organized medicine destroyed the burgeoning quality analysis movement early in the century, and how even as late as the mid-1990s, medical providers who became quality focused and more cost-effective found that they were losing money as a consequence.  The problem then was that managed care payers weren’t sophisticated enough to pay based on quality and performance, so the old fee-for-service paradigm of do more, get more actually rewarded poor quality care. Millenson’s expectation was that over time as more aggressive payers realized that quality was synonymous with lower costs, pay for performance would replace fee-for-service.  (For a contrary view see JD Kleinke’s Oxymorons, where JD decides that after preaching about the virtues of the market for all those years, better health care is just more expensive).

Well, now the New York Times is coming around to Millenson’s view. In an article called Hospitals Say They’re Penalized by Medicare for Improving Care, the Intermountain system in Utah claims that it’s providing great quality care, getting it right the first time and not having to redo procedures or transfer patients to higher intensity settings. As a consequence it is losing out on Medicare payments. Millenson’s book has a very complimentary section on Intermountain, and it’s no coincidence that Intermountain is among the most computerized health systems in the country and has been for years.

According to the Dartmouth Atlas, Utah certainly has lower rates of surgery than Colorado next door. Of course you don’t really know the incidence of disease behind this variation. This led to the great comment at a meeting I was at from Larry Weed: "You don’t know whether to move to Denver to get your problem taken care of properly or go to Salt Lake City to avoid unnecessary surgery." My pretty strong hunch is that you’re better off in Utah (even if it’s murder getting a drink there unless you know where to go).

The Times then suggests that getting Medicare to "pay for performance" is the answer, as suggested by the Jackson Hole veterans in Health Affairs, although I was somewhat disparaging about the concept’s prognosis yesterday. Apparently Tom Scully thinks it’s a good idea, and the Times says he is:

Of course the minor problem is that years of data suggests that the for-profit hospital sector that Scully represented during the 1990s is the worst offender in terms of doing too many procedures that are medically dubious and of low quality; our buddies at Tenet being among the worst examples. I bet you all a nickel each that when Scully is back in the private sector he’ll be making sure that his clients don’t have to worry about Medicare forcing them to really change their ways–that is unless those Mormons can come up with some serious cash for lobbying.

A 13 girl died this weekend after skiing into a tree at Alpine Meadows near Lake Tahoe. I’m a very keen skier and snowboarder and, although I wasn’t close to dying, I tore 3 ligaments in my knee after snowbaording into a tree last year. So I have a deep personal interest in the subject and have been evaluating knee guards as I get back onto the slopes.  What surprised me is that the girl was wearing a helmet. You’ll find that many skiers are wearing them these days, but apparently they don’t help in every case.

A study in the BMJ said, apparently with the approval of the UK health minister John Reid, that Kaiser Permanete provided better care than the UK’s NHS at better overall value and similar cost! This follows an academic report that suggested that UK care standards should become more like American ones. No, they’re not thinking of importing our insurance industry, but this is suggesting that length of stay in the UK is too long and should be brought in line with best American practices.  That’s not too far wrong in my view.  LOS over here is too short, forced that way by per admission DRGs, but not grossly so. Whereas LOS in most other countries is 2-3 times as long and lowering it would mean that care could be better delivered in the community at lower cost–rather than in a SNF at higher cost as is often the case in too-early discharges here. (In Uwe Reinhardt’s argument this leads to higher than necessary average inpatient costs as the first day in a SNF actually costs more than the last day in a hospital). I  know something about international comparisons (as well as something about Kaiser and the UK), and there is a nugget in here which I’ll bring out more in the future. 

Meanwhile, think about this on the macro level;, the Brits are looking for ways to cut cost in their system and they’re spending less than half what we do! And consider one more thing–costs in Florida are twice what they are in Minnesota, so we could do the same thing if we wanted (and could be bothered to read Wennberg’s stuff).

Hat tip to the wonderful MedPundit for this story, although why is a good free-marketeer like Sydney trolling the news outputs of a nationalized monopoly business like The BBC? Maybe there’s something to that socialism thing after all??