Who doesn’t love a Top 10 list? Creating them is an art form. So when it was formally proposed by Dr. Brody in 2010 in the NEJM that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.
“The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit,” he wrote.
And yet, thus far the only groups that have seemed to have taken him up on the suggestion have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics – notably amongst the least compensated fields in health care.
This is a great start, but c’mon guys, where are the rest of you? Dr. Brody wrote you a “prescription.” We have a term for your behavior: “noncompliance.”
Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an impressive list of organizations participating in their “Choosing Wisely” campaign. They also have begun to be instrumental in funding projects towards this goal. Costs of Care has highlighted far-reaching areas of non-value-based care, including a recent thoughtful essay about robotic surgery. We must now consolidate on these small gains and move this forward across all specialties in medicine.
The concept of practice variation raised its ugly head again this weekend in the northern California news media. And buried in the stories are several themes for our ages. But the conclusion is, the power of individual health systems and very small numbers of physicians to change patterns–and the cost–of care are enormous.
First the stories. Both about health care but also both revealing the future of investigative reporting. The BayCitizen is a non-profit blog about the San Francisco metro, created as response to the local papers cutting their reporting. It also provides stories to the NY Times–I’m unaware about how much of its revenue comes from the Times, but it’s part of the Times’ entry into non-NY competition with retreating local papers.
For this story on heart program readmission Katharine Mieszkowski picked up on an older UCSF press release and showed how UCSF used a $500K+ donation from the Gordon & Betty Moore Foundation (that’s the Moore of Intel & Moore’s law fame) to create a very sensible program that gave in-home support to newly discharged elderly cardiac patients. It cut readmission rates by 30%. The BayCitizen though will upset Gary Schwitzer as it did not include the actual numbers but the UCSF press release does, and yes this is a relative not an absolute cut. Here’s the key graf
Over the past 11 months, only 16 percent, on average, of the hospital’s heart failure patients were readmitted within a month of discharge, down from 23 percent in 2006. That’s well below the national 30-day readmission rate of 25 percent. The average readmission rate was 11.6 percent during the first four months of 2011.
So UCSF was about average and got much better and seems to be getting better still–but there’s quite a way to go. But it is an indication that at least one AMC is capable of moving the ball in the right direction. Of course UCSF is a leader in the pro-Dartmouth “use resources sensibly” camp, and we may or may not see the “keep em alive at all costs” folks at UCLA follow suit.
Meanwhile up in rural northern California it looks like the same Dartmouth data set is about to bring a series of visits from the FBI. Continue reading…
I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.
Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.
But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.
It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.Continue reading…