The Health Care Blog – Page 382 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Guideline-Centered Care

Jan 30, 2016• 2

By JOHNATHON TOMLINSON, MD

flying cadeucii Doreen, Ahmed and Henry have recently had their medication changed in response to a new guideline for prescribing Statins, cholesterol-lowering drugs.

None of them came to ask for a change in their medication. In each case the change was recommended by a clinician in response to a new guideline against which our practice will be judged and financially rewarded or penalised.

Here are the NICE guidelines 2015:

The NICE guideline on lipid modification recommends that the decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy.

and

NICE recommends that statin treatment for people with CVD [Cardio–vascular disease] (secondary prevention) should usually start with atorvastatin 80 mg daily.

It is very easy to judge whether or not people with CVD are on Atorvastatin 80mg, but almost impossible to judge whether the decision to start therapy has been made as a result of thoughtful deliberation between the patient and the clinician. Thoughtful deliberation is at the heart of patient-centered care – not doing whatever the patient wants, as is often confusingly assumed.

Employer Sponsored Insurance: Unfair and Unaffordable

Jan 28, 2016• 5

By ROGER COLLIER

flying cadeucii For all those Americans faced with higher health insurance premiums or less coverage (that’s most of us), the temptation is to blame the Affordable Care Act. Maybe instead we should be blaming the one thing the ACA didn’t significantly change: employer sponsored insurance—the norm for most working Americans.

Although the ACA imposed some new standards for coverage, ESI employers remain free to dictate most insurance details, the tax-exclusion of ESI benefits is largely unchanged, ESI premiums are still generally independent of income, and small employers can still offer ESI or not.

Unfortunately for millions of workers, it’s a model that’s increasingly neither affordable nor equitable. What seemed a reasonable approach fifty or sixty years ago when healthcare costs were far lower is now one of the most regressive health insurance systems in the industrialized world.

The Kaiser Family Foundation’s most recent employee benefits report demonstrates the problem.

Enduring Effects of Trauma in Newtown and Beyond

Jan 28, 2016• 1

By JOAN COOK and MARJORIE S. ROSENTHAL

https://youtu.be/ZF7YbDlqPWQ

This month’s Sundance Film Festival, a 10-day salute to movies that are often hailed as tapping into the national zeitgeist, have two films this year on gun violence: Katie Couric’s “Under the Gun” and Kim Snyder’s “Newtown.” Both will be screened by influential audiences this week with a plan for larger distribution over the year. And both will no doubt question what we as Americans should do to prevent mass shootings and to heal afterward.

The ripple effects of mass shootings are immense. Earlier this month school leaders in Newtown testified to Connecticut’s state board of education about the ongoing mental health difficulties that children in Newtown are having three years after the massacre at Sandy Hook. As a trauma psychologist and a pediatrician, we were saddened, but not surprised, by this report. Working in New Haven, just 20 miles from Newtown, we both have colleagues and patients who are in those concentric circles of Sandy Hook and have felt the effects in our professional and personal lives. As health care professionals, mothers, and neighbors of Newtown, we wondered what we as a nation have learned about long-term healing in places like Columbine and Virginia Tech.

Data Socialism

Jan 26, 2016• 4

By SAURABH JHA, MD

In an unusually candid editorial in the NEJM, Longo and Drazen say that data sharing may be problematic because some researchers fear that the data could be used to by others to disprove their results. The editors predicted a new class of researchers who use data created by other researchers without ever taking the trouble to generate data themselves – research parasites.

With this editorial, the NEJM has firmly established itself as descriptive (the way the world is), rather than normative (the way the world ought to be). I, for one, find this move rather refreshing. I have been pumped to a diabetic state by the saccharine naivety of the hopey-changey, “we need this and that” brigade. The editors merely said what some researchers secretly think, and how many actually behave.

Why Are Physician Engagement Scores So Dismal?

Jan 25, 2016• 4

By RICHARD GUNDERMAN, MD

Gunderman Many hospitals around the nation have been stung by dreadful physician engagement scores. Engagement is a problem not only for demoralized physicians, but for healthcare organizations, their employees, and everyone they serve. They should take note, because low levels of engagement are associated with higher physician turnover, increased error rates, poorer rates of patient cooperation in treatment, and lower levels of patient satisfaction.

Definitions of engagement vary, but it generally includes pride, loyalty, and commitment. When engagement scores are low, physicians take little pride in the hospital, would not recommend it to a job-seeking colleague, and believe that the hospital’s mission and vision are not in sync the needs of patients. On the other hand, engaged physicians are more likely to perform better in every area, including patient care, education, and research, which benefits everyone.

To better understand the roots of poor physician engagement, I recently sat down for a conversation with a large group of students from the Indiana University Kelley Business of Medicine MBA program. Its students are practicing physicians from around the country who have realized that to improve patient care they need to become better leaders. Many work in hospitals that have identified engagement challenges and are attempting to develop solutions to the problem.

Data Parasites?

Jan 23, 2016• 2

By DAVID SHAYWITZ, MD

flying cadeucii In just four years, it seems, data science has devolved from the “sexiest job of the 21^stcentury” to a community of “research parasites.”

The latest assessment is courtesy of an editorial in the New England Journal of Medicine (NEJM), written by editor-in-chief Jeff Drazen, along with Dan Longo.

Essentially, Longo and Drazen argue that while the Platonic ideal of rich data sharing is lovely, reality is not so pretty.

First, Longo and Drazen allege, researchers who weren’t involved in gathering the original data often lack essential appreciation for how it was gathered, and thus may misinterpret it, as they “may not understand the choices made in defining the parameters.”

Second–and this is really the heart of the issue–Longo and Drazen worry that a new class of research person will emerge—people who had nothing to do with the design and execution of the study but use another group’s data for their own ends, possibly stealing from the research productivity planned by the data gatherers, or even use the data to try to disprove what the original investigators had posited. There is concern among some front-line researchers that the system will be taken over by what some researchers have characterized as “research parasites.”

The Patient-Centered Health Record

Jan 23, 2016• 8

By PETER ELIAS, MD

The other night I participated in a very useful Google+ hangout with Adrian Gropper, Michael Mascia and Michael Chen. The discussion focused on a subject I think is incredibly important: the patient-centered health record. Unfortunately, this topic is hard to discuss without drowning in technical terms and acronyms. I consider myself fairly tech-savvy and still struggle.

A (55 minute) YouTube video is here: Click here

I think it is worth watching. before watching it, consider reviewing the following basic information to help set the stage, first without tech terms or acronyms, and then repeated with some of the key jargon.

The current EHR model is that each office or institution owns and manages an electronic record that contains information about the patients in that system. Despite the obvious need and lots of talk, there has been little actual progress towards making these separate and mostly proprietary systems ‘interoperable’ and therefore able to share information. The result is that clinicians routinely work with incomplete or outdated information, patients are locked into their home system, and it is extremely hard for patients to access their own information in any meaningful or useful way. Care is less safe and less reliable, patients are prevented from actively managing their care, and clinicians are frustrated.

Will the Pharmaceutical Industry Learn From Past Mistakes?

Jan 22, 2016• 3

By SOEREN MATTKE, MD

Soeren Mattke Awash in negative headlines, public condemnation and government scrutiny, the pharmaceutical industry faces a public relations problem that, left untreated, could bring new regulations or sanctions either from governments or the courts. At the same time, though, the recent scandals over price gouging could offer an opportunity for responsible, research-based companies to distance themselves from the profiteers.

The industry has come under fire at a time of unprecedented innovation. As a physician who trained in the 1990s, I am in awe of the recent breakthroughs. Immuno-oncology drugs like Keytruda (pembrolizumab) and Opdivo (nivolumab) offer hope for patients with previously untreatable cancers. Entresto (sacubitril/valsartan) – the first novel treatment in over a decade for congestive heart failure, a condition deadlier than most cancers – was approved this year. There is a cure for many forms of Hepatitis C with Sovaldi (sofosbuvir) and vaccines for dengue fever and maybe even malaria may become available soon. More patients in developing countries than expected have access to antiretroviral drugs for HIV/AIDS and companies are devoting resources to achieving the same for the new scourge of noncommunicable diseases.

At the same time, some in the industry have been seeking to tackle the image problems. Overeager sales representatives are being reined in. Financial ties to physicians and clinical trial data are being disclosed. The main industry bodies in the United States, PhRMA and BIO, disowned Turing Pharmaceuticals, the company behind the notorious 5,000 percent price increase for Daraprim, a critical drug for certain infections in immunocompromised patients.

The Unaffordable Care Act

Jan 21, 2016• 22

By DEVON M HERRICK

Liberal public health advocates and left-of-center health policy wonks have long thought every American needs health insurance (they don’t, but that’s another discussion). Lefties assume health insurance is the only way Americans access medical care. After all, the purpose of the Affordable Care Act was to insulate Americans from the financial hardship of medical care they couldn’t afford to pay for out of pocket. Moreover, many pundits believe having to reach for one’s wallet during a medical encounter is unacceptable. So imagine my shock when I read a headline in The New York Times claiming that Obamacare is no guarantee against crushing medical bills.

In a survey of non-seniors, the New York Times/Kaiser poll found about one-in-five people struggle with medical bills even though they have insurance. Among insured people who reported crushing medical debts, about three-quarters reported putting off vacations, major purchases and cutting back on household spending. Nearly two-thirds used up all or most of their savings. Far fewer had to resort to second jobs, take on more hours or ask family members for funds (42 percent to 37 percent).

Why are these insured Americans having to reduce their standard of living and, in fewer instances, having to resort to more drastic measures? Was it entirely because they’re sick? A common refrain among those struggling with medical bills was that money was tight prior to a family illness. This includes high-income households as well as low income households.

FHIR: The Last, Best Chance to Achieve Interoperability?

Jan 20, 2016• 3

By DAVID SHAYWITZ, MD

Can an impassioned band of savvy, battle-tested techno-optimists save our healthcare system from its worst instincts, and deliver at least a soupcon of real interoperability?

That’s the question I found myself seriously contemplating after last week’s JP Morgan Healthcare Conference in San Francisco, and in particular after an inspiring data science roundtable discussion led by Aneesh Chopra (the first Chief Technology Officer of the United States, now at Hunch Analytics) and Claudia Williams, a senior advisor in the White House Office of Science and Technology Policy (OSTP).

The FHIR Engine

The (not so) secret sauce in question is the FHIR (pronounced “fire”) interoperability standard that has emerged from the non-profit HL7 organization, and functions as a universal adaptor, allowing some types of clinically-relevant data types to be shared easily and securely. Remarkably, most major electronic health record (EHR) vendors – including athenahealth ATHN +0.00%, Cerner CERN +0.00%, and yes, Epic — have signed onto this concept, and agreed to support an early effort at implementation, known as the Argonaut Project.