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QUALITY: The nursing shortage, with UPDATE from The Industry Veteran

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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

PHARMA: More on big pharma’s marketing and sales strategies

And in continuing rumblings from the pharma marketing corruption story THCB reported on a week or so back — Schering was mailing physicians checks to get them to prescribe their drug — a couple more missives have crossed my desk. They concern how pharma companies market both in terms of how they deal with physicians, and in terms of how they choose their sales force and marketing strategies. It appears that there is room for major change in the latter. And as I mentioned in passing in a previous article about margins in the drug business, this whole sales and marketing arena is ripe for cost reduction and efficiency enhancement.

The first piece was sent to THCB is from Random Contributor who writes in a somewhat scurrilous vein:

    In short, pharma companies bribe physicians because it works, physicians expect it, and it doesn’t take much imagination. In a world in which there are many clinically similar drugs packed into each of a few high-return clinical categories – and a bunch of drug companies whose future rests on their performance in those clinical categories – docs can safely make prescribing decisions on things other than clinical performance. Prescribing Zocor instead of Lipitor won’t kill a patient,but it could enrich the doctor prescribing it…

    It’s hard to argue that drugs aren’t "overpriced" if payoffs are built into their pricing schema. So how much would this drug cost if you didn’t pay docs millions to prescribe it?

    As a quick aside, I was talking to my uncle (72 years old) who lives in Florida. His doc (internal med) recently gave up hospital privileges and malpractice insurance, but continues to practice primary care. He told me that his doc "plans to make up the difference through seeing more patients and prescribing more drugs." Don (my uncle) listed several of the drugs that he is taking (Plavix, Provachol, etc.) and I noticed that they were primarily from BMS… I wonder if there is a connection (or if his BMS rep is just really hot)?

While the Contributor is probably overstating the case–after all physicians don’t actually make money from prescribing drugs (unless they’re oncologists or in Japan), but it’s no secret that some doctors and some reps have particularly close relationships and that much pharma detailing is made very effective by leaning on those personal relationships. Meanwhile, the whole concept that pharma does it one way because it always has is also probably true. That’s partly why detailing and professional marketing only works effectively on less than half of physicians. The rest of all the reps in the sharp suits/push-up bras hanging out in the waiting room to get 30 seconds with the doctor is mostly waste motion.

But that might all be changing. Pfizer, which won the pharma arms race of the 1990s by building up its sales force when others were cutting back and trying to ingratiate themselves with managed care companies, or buying PBMs, is now looking to cut its global sales force, use CRM software to more accurately support its physician "customers" and eliminate the "significant number of calls where product market messages are not delivered and where there’s little to no value to the physician." In other words the Bludgeon needs to be replaced by the Rapier.

This new way of thinking might even extend to advertising and PR-type promotions. I am on a list-serv from Pharmaceutical Marketing Network, and recently this somewhat bitter screed about the sloth in thinking and consequent incompetence of pharma marketing was posted by Brian Towell from Doghouse, an online marketing agency. I repost it here because although I don’t agree with it all, it certainly puts the marketing strategies of pharma into sharp focus:

    The operational procedures of the large drug companies never cease to amaze me, particularly at the level of procurement of medical communications (which includes vanity publishing aka MedEd, Advertising, Branding, Congress & Scientific Meeting Event management, Professional Relations and Public Relations, along with some other City/Stockholder targeted communications that none of us ever see or hear about.) All of these served by agencies with global and/or local expertise, and often with ridiculous levels of duplication, isolation and total lack of connection with the brand.

    The procurement process is flawed for all, however you look at it. In America, ‘Global’ means everywhere else, whereas in Europe, ‘Global’ means everywhere, so US sited businesses are strangely infatuated by their own agencies, who are collectively useless at almost everything, but manage to hoodwink their clients into accepting dull and sub-standard creative work because that’s what everyone does in the US. In Europe, despite the rise and rise of the European community, the cultural and regulatory differences that exist on a country to country basis make it impossible to engage at head office level with a Novartis or a Roche on a ‘Global’ basis without some kind of network that allows differing cultures and medical legal systems to be managed profitably, and with due diligence.

    Unfortunately, the problems of both major markets (US & Euro) conspire to produce an industry of communications service providers inadequate in creativity and strategic bravado (largely serving tactical briefs) who somehow manage to continue to exist and grow alongside a healthcare industry that is rotten with stagnant process, and trapped by its own strategic immobility.

    The world is leaving Big Pharma behind. Agencies need to become smaller, more responsive, and more strategically driven, to help the industries that support them to make more responsive, dynamic choices and decisions, and to to open a portfolio of strategies that provide a meaningful escape route from the conventional, stagnant practice that all involved seek comfort in.

    The idea that these companies set up rosters of ‘preferred providers’ is obscene, and simply appalling business. Even the Schering Plough reverse auction idea was only open to their cute list of favorites, who they get along with really well, who never surprise or challenge them, and allow the same stuff to keep rolling along like an endless roll of Magnolia tinted wallpaper. Sameness is a real issue for the industry that needs to be challenged, instead of propagated ad nauseam.

    Thought innovators within the industry are now pointing to the reality of a ‘here and now’ strategic inflection point for big Pharma, where yesterday’s choices (strategic traps) and ‘already thought’ behaviors become not just redundant but unsustainable. Whatever the Big Companies continue to do in that vein are simply expressions of improved effectiveness at inefficiency.

    It is a self-propagating world of publications and activities that is, under the sharpest magnifying glass, difficult to justify and difficult to benchmark in terms of any contribution to the business. Its poor quality, and it costs. But no-one measures that cost.

    Novartis ask questions of providers that they must answer in a 10 slide powerpoint presentation, to get to 2nd base. But they don’t ask the right questions. What can you meaningfully contribute to our business? Show us. 2 questions. Tough call. That’s how it should be. Not a 45 minute display of last year’s work that fits our neat idea of how we have always done things here.

    That’s all it should be. Then maybe the people who work in Healthcare Communications Services would wake up to some home truths about what they’re actually doing for their clients, instead of churning out the same ‘already thought’, safe, and largely generic tripe that no other industry would tolerate.

POLICY: Scully guilty, but not legally, with BRIEF UPDATE

In a splitting of hairs in a report from the HHS inspector general, Tom Scully the administrator of CMS when the Medicare bill was passed, was found guilty essentially of lying to Congess. In fact while Scully pressured the main CMS actuary so that he didn’t reveal that the MMA would cost more than $500 billion rather than the $400bn that the Administration told Congress, he didn’t break the law in doing so.

The irony of all this is that despite the huge pressure the Administration and the leadership brought to bear mostly on House conservatives to vote for the bill, its passage has probably been a negative for the Administration, and will probably be a liability come November.

UPDATE: While neither this story nor the related ongoing enquiry into the bribery on the floor of the House while the bill was being voted on, probably won’t make much difference in real life (i.e. the election), The NY Times report on this story has a couple of juicy factoids:

    In recent weeks, Mr. Scully has registered as a lobbyist for major drug companies, including Abbott Laboratories and Aventis; for Caremark Rx, a pharmacy benefit manager; and for the American Chiropractic Association and the American College of Gastroenterology, among other clients. All are affected by the new Medicare law, which Mr. Scully helped write.

And Pete Stark gets his snide oar in there.

    Representative Pete Stark of California, the senior Democrat on the House Ways and Means Subcommittee on Health, said, "It sounds as though the Bush administration examined itself and found it did nothing wrong."

QUALITY: Hospitals remain dangerous, but talking about the issue makes them safer

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.

INDUSTRY: Is nothing sacred? Cardinal admits sinning

OK, not really, but serious bad news at what has been one on the health care industry strongest performers and best run companies. Cardinal Health anounced that it would miss profit forecasts, and was being investigated by the SEC. The stock is off 25%. The Street.com has (for them) a balanced article including this juicy quote from one analyst: ‘Multiple investigations, lowered guidance and a hazy outlook on growth have shaken our thesis that CAH is a ‘buy and hold forever’ stock,’ Wieland concluded.". Of course regular THCB readers know what’s coming next. I bought a small amount of Cardinal stock on a slight dip as part of my "sensible" portfolio last month! Oh well, back to crazy biotech companies with no revenue–they’re clearly safer!

POLICY: One in five households struggle with medical debt

I’m moving today and tommorrow so dont expect much real thoughtful action here until next week. However, I’ll list a few bits and pieces you should keep up with.

As you’ll recall in my comparisons of Canadian and US healthcare systems (in my Oh Canada piece and elsewhere) the major issue for lower income Americans is their problems paying the bills associated with medical care. This is virtually unknown elsewhere in the civilized industrialized world. HSC has a new report out showing that 20 million families, which is about 20% of households, in the US have serious problems with medical bills, including having to choose between paying them and paying rent.

With a little more of this rhetoric, health care just might become a slightly more important issue for this election cycle. It’s more likely though that this will continue to build up until the dam bursts in the latter part of this decade, and we engage in a full-scale national debate a la 1992-4.

HOSPITALS: Pity poor ex-Tenet CEO Barbakow

Jeff Barbakow was the CEO in charge of Tenet at the time of their stock collapse following all the goings-on at their Redding, CA, facility and elsewhere. Although he cashed out nearly $111m in Tenet stock a few months before the scandal broke and the stock crashed, he apparently lost a fortune on Worldcom stock, when it went into bankruptcy–also after massive fraud. But proving that this is a great country, he’s suing to get his money back! At least Tenet hasn’t quite yet followed Worldcom in Chapter 11.

PHARMA: The Industry Veteran and friends blame (mostly) the doctors

So following Sunday’s NY Times article on bribes being paid for prescribing and my comments yesterday, the Industry Veteran let me in on some email exchanges going on round his electronic watercooler. You’ll note that he and his colleagues do not ascribe most of the blame to pharma:

    This morning a friend who teaches marketing at a local university e-mailed to me an article from yesterday’s NYTimes. The subject line of his e-mail read, "Just how stupid is Big Pharma anyway?" I am forwarding to you my reply to him. I think my reply will again tweak the noses of your physician readers who consider themselves healthcare’s good guys because I believe physicians hold equal or more blame for the system of pharma-to-prescriber payoffs now coming to light.

The Veteran’s reply to his friend:

    ‘In this case I don’t think it’s a matter of stupidity as much as systemic incentives and culture. Whenever fiduciary gatekeepers (e.g., healthcare professionals) are inserted into a market system, there will always be an enormous temptation to influence their decision-making. It’s the same with company purchasing agents and government contract committees. From the NYTimes article, one might as easily admonish physicians as the pharma companies. If you were to speak with the marketing and sales people who develop these payoff programs, I’m sure they’d all say that the docs expect it and that if their company were to opt out the payoff system, their competitors would get all the business.I’d make the argument that over the past 40 years, the development of physicians’ unbridled avarice represents a bigger change than any supposed penchant for corruption on the part of Big Pharma. After years of attending scores of brand team meetings at all the Big Pharma companies, I’d go so far as to say that in most cases where baldfaced, baksheesh programs are developed, the driving force is usually one or more of the physicians in the room. As a curbstone assessment of their underlying psychology, I suspect that they typically seek to impress other team member with their machismo and their marketing acumen. Their payoff initiatives represent an attempt by arrogant ignoramuses to figuratively say, "What’s so tough about this marketing stuff? Hell, I’m not just a clinical nerd. I’ll show you marketing."’

A little later the Veteran copied some more correspondence into THCB

    I wanted a reality check on the reply that I sent to my academic friend this morning. After sending it you (i.e THCB) I also forwarded it to an acquaintance who has worked for 20+ years in the industry. Unlike my dangerously subversive political views, his are hard core, Reagan-Bush right wing. He is, however, scrupulously honest and empirically open-minded. I pass along to you his comments in anticipation of the fusillade from the medical practitioners of negotiable virtue.

    "I agree with your message back to _____: the $$ demands of MDs are just amazing. And having been in marketing most of my career (launched two products and Director of Marketing for a biotech company), I can tell you that most of the time pharma is in reactive mode. Those who are strong enough can resist the demands* of the purveyors of the Hippocratic Oath, but it is difficult for the very reason you mentioned: at some point, you know you’ll get left in the competitive dust. And one of the biggest jokes is biotech. Many, if not most of their top honchos are ex-academic researchers. In my experience the majority of them are not at all cognizant (nor do they care) about such trivialities as FDA guidelines or anything that they believe applies only to the dirty, big pharma companies. In their way of thinking, biotech is much too cerebral and pure to be lumped in with the pharma industry."

    *Just look at how the cost per patient of legit clinical trials has zoomed the past 10-12 years; clinical investigators will take on any trial if the price is right.

INTERNATIONAL: Canada’s Liberal Party Loses Majority

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So after all the fuss about Canada possibly changing political horses, the election result shows that the Liberal Party got much more of the vote (37%) than the conservatives (29%). Due to the way Canada’s parliamentary system works (and because of the gains by the Quebec nationalists), PM Martin will have to form a coalition government. But the impact on the health care system will likely be neglible, as both sides more or less want to keep it as it is and both have promised to spend more money on it.

PHARMA: Hands – cookie jar – once more a connection

If you missed this over the weekend, the New York Times reports on yet another example of very dubious marketing practices by certain pharma manufacturers. This time the charges are that Schering (more or less) paid doctors to prescribe drugs. Anyone watching the health care system for any length of time is used to this. It’s rare that it’s this overt, although it was when Caremark was paying for infusion referrals back in the early 1990s, but sweetening the route to ensuring the right drug ends up written on the prescription pad has always been a big part of pharma’s marketing approach. While there are some limits that since the late 1990s are supposed to be placed on what the local marketing teams can do, the pressure remains on to make the physicians happy, whether it be via Dine and Dashes, free goodies, consulting agreements, or simply having a rep show up that the doctor will enjoy meeting (and I’m not spelling that out for you!).

The NYT suggests that this will only get worse as more and more of the pharma dollar gets spent by the government, and hence more and more of this bad behavior will be punished by Federal fines. As it’s been an accepted cost of doing business by the pharmas for a long time, and as the government really hasn’t got the option of giving them the "death penalty" (i.e. banning them from the Federal marketplace), expect this cycle–bad behavior, then punishment, then official reform, then more local level bad behavior, more punishment, more reform, new bad behaviors, etc–to continue.

By the way, if (as reported in the article) anyone out there wants to send me a consulting agreement accompanied by a large check with a blank schedule of works to be performed at some unspecified time in the future, they will find that I have few fewer ethical qualms in accepting it than the anonymous physician interviewed by the NY Times!

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