The Health Care Blog – Page 396 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Payers Join the Healthcare Team

Oct 12, 2015• 1

By ED CHUNG, MD SPONSORED CONTENT

Back when I was in medical training a decade ago, patient rounds were usually conducted by a group of physicians. We’d walk down the ward, visiting patients and scribbling notes as we went. If we were feeling particularly inclusive, we might bring nurses along. But that was as diverse as the care team got. Even the concept of a “care team” was only just starting to take hold on wards where highly complex patients were being cared for.

These days, the picture looks quite different. Now, in addition to doctors and nurses, we have pharmacists, social workers, therapists, nutritionists, and case managers joining us on rounds.Continue reading…

Is ProPublica the Paul Revere of Transparency?

Oct 11, 2015• 24

By SAURABH JHA, MD

Recently, I was speaking with a “less is more” advocate. He used his superior knowledge of statistics – he had an MPH – to debunk randomized controlled trials. We discussed overdiagnosis, overtreatment, and the shakiness of medical sciences.

We spoke about measuring the quality of physicians. I remarked that quality metrics have as much evidence as Garcinia Cambogia – we had just laughed about Dr. Oz. I expected a chuckle. Instead, he became distinctly uncomfortable and, in a solemn tone, lectured me about the Institute of Medicine (IOM) report, “To Err is Human.”

The physician, a bulldog of evidence-based medicine (EBM), had a blind spot. He ripped cardiologists for overusing pacemakers. He believed in the usefulness of the physician quality reporting system. He disdained big pharma for pushing statins. He was a fan of maintenance of certification. He was at once a raging skeptic and a true believer.

My understanding of statistics is modest compared to his. But I am skeptical by nature. I’m skeptical of many things including (not necessarily in this order): statins in 65-year olds, kumbaya, hellfire, England’s soccer team, quality metrics, screening (much to the chagrin of my radiology colleagues), high priests, middle priests, hard drives spontaneously combusting, and futurists. I’d like to believe this is because I’m a dark knight searching for the truth. The reality is that I’m just a cynical git who was raised in an island where it rains without remorse. My skepticism manages to offend a unique human every day.

The Goose and The Elephant

Oct 10, 2015• 2

By BRIAN KLEPPER

America’s drug and biotech industries are no doubt alarmed by the national firestorm that erupted when Turing Pharmaceuticals raised the price 55 times of its 62 year old lifesaving drug, daraprim. They must worry that CEO Martin Shkreli’s tone-deaf reactions to the public’s scorn could precipitate close scrutiny of broader drug industry dynamics. The last thing pharma wants is a vigorous, in-depth national discussion of pricing, value, what we can afford and how other advanced countries handle drug spending. All this could kill the golden goose.

Seeking distance from the furor, PhRMA tweeted that “Turing Pharma does not represent the values of PhRMA’s member companies.” Then BIO, the biotech industry’s association, rescinded Turing’s membership and returned its dues, the equivalent of booting Turing out of the country club.

You can hardly blame them. In the US, pharma has engineered a great sweetheart deal. Once a drug is FDA-approved, the law dictates that Medicare must pay whatever a manufacturer demands, without negotiating, and that pricing sets a reference for the rest of American drug prices. Peter Bach, MD, who leads Memorial Sloan Kettering’s Center for Health Policy and Outcomes, summed up our dilemma earlier this year:

[Drug] companies are taking advantage of a mix of laws that force insurers to include essentially all expensive drugs in their policies, and a philosophy that demands that every new health care product be available to everyone, no matter how little it helps or how much it costs. Anything else and we’re talking death panels.Continue reading…

What the World Might Look Like If We Taught Docs How to Hack Spreadsheets

Oct 10, 2015

By HAYWARD ZWERLING, MD

I am an IT geek physician. I have my an EHR which I created and control.

Today, I wanted to understand my diabetic practice a little more, so I dumped all my HbA1c data out of my EHR and into a spreadsheet where I was able to manipulate the data and learn a few things about my practice.

I learned that:

If my patient had a HbA1c ≥ 8, the likelihood that the HbA1c would be < 8 at the next visit is 68%.

If my patient had a HbA1c ≥ 8, the likelihood the HbA1c would be even higher at the subsequent visit is 29%.

If my patient had a HbA1c ≥ 8, the average change in the HbA1c at the next visit was -0.7.

If my patient had a HbA1c < 8, the likelihood that HbA1c at the subsequent visit would exceed 8% would be 15%.

Shared Baselines as a Guide to Protocols

Oct 10, 2015• 5

By PAUL LEVY

There have been some interesting and important discussions flying across the web in recent days on the issue of protocols in helping to reduce variation and reduce the incidence of harm to patients. My mistake in the debate was assuming that medical leaders would be reasonable about how protocols should and should not be used.

A doctor friend, highly committed to patient safety, notes:

My point about the protocols is that I have been chastised for not following them in situations where it was blatantly obvious that they did not apply. (“The protocol is there for a reason.”)

The chastisement comes not from hospital administrators, but from clinician leaders in the doctor’s own department:

We just got another email scolding us for not following the “colorectal pathway” sufficiently. One of the provisions of that pathway, for example, is strict limitation of iv fluids, sometimes difficult to “comply” when patients are severely dehydrated from their bowel preps, particularly the elderly.

The initial goals were to decrease opiate use and decrease PACU LOS, both worthy goals, but we’re all annoyed at being beaten over the head with them and getting our hands slapped if we deviate, even with good reason.

It’s ironic that on the one hand we are extolling the virtues of gene-based individualized therapies, but on the other hand we are trying to pigeon-hole every patient into a standardized protocol.

Healthcare Startups – Why Now and So What?

Oct 9, 2015• 7

By LEONARD D’AVOLIO

It’s 8:15 on Friday evening. I’m almost through editing the job description for a user interface engineer after sending off an introductory slide deck to a potential client. Today I met with a business development prospect, held calls with a potential advisor, a potential client, and finally made those changes to the website. There’s not time to write this but when will there be?
I’m part of a growing trend of academics, programmers, and clinicians taking the startup path to try to make healthcare a better place. In fact, record breaking amounts of venture funding are pouring into healthcare with 2014 seeing $4.13 billion in digital health venture funding and 2015 showing no signs of slowing. Established tech companies not typically associated with healthcare including Apple, Samsung, Google, and IBM are getting in on the act with substantial investments. It seems that nearly every hospital and insurer is launching its own incubator or innovation fund.

The real question is why, after decades of lagging behind nearly all other industries in the adoption and use of information technology, does healthcare seem to suddenly be such a hotbed of activity?

The answer: data matters like never before in healthcare.

Rehabilitating Health Charities

Oct 9, 2015• 1

By NORTIN HADLER, MD

Fall is when I attend to charitable contributions. It is the season for writing all those checks in a timely fashion so that I’ll receive the paperwork needed to garner tax credits. My wife and I want to do what we can to soften the hardships of those whose ability to do for themselves is compromised. It is a moral obligation, explicit in the Old Testament: The giving of charity is a duty for the advantaged and the receiving of charity a right, even an obligation according to Maimonides, of the needy. Alms-giving is one of the Five Pillars of Islam. Pope Francis embodies the Christian tradition.

Misunderstanding ProPublica

Oct 8, 2015• 20

By ASHISH JHA, MD

In July the investigative journalists at ProPublica released an analysis of 17,000 surgeons and their complication rates. Known as the “Surgeon Scorecard,” it set off a firestorm. In the months following, the primary objections to the scorecard have become clearer and were best distilled in a terrific piece by Lisa Rosenbaum. As anyone who follows me on Twitter knows, I am a big fan of Lisa –she reliably takes on health policy group think and incisively reveals that it’s often driven by simplistic answers to complex problems.

So when Lisa wrote a piece eviscerating the ProPublica effort, I wondered – what am I missing? Why am I such a fan of the effort when so many people I admire– from Rosenbaum to Peter Pronovost and, most recently, other authors of a RAND report – are highly critical? When it comes to views on the surgeon scorecard, reasonable people see it differently because they begin with a differing set of perspectives. Here’s my effort to distill mine.

An Error about Mistakes

Oct 7, 2015• 8

By PAUL LEVY

There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women’s Hospital in Boston. So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes. Read the whole thing and then come back and see what you think about the excerpts I’ve chosen:

“The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.”

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error. The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes. The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost’s work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

In Defense of Mistakes

Oct 7, 2015• 7

By MARTIN SAMUELS, MD

“How much of the medicine that you now use, did you learn during medical school?”

My answer may be surprising. It is not the response given to me by my professors, when they were asked similar questions. I recall them telling me that virtually nothing that I was learning in medical school would be correct 20 years later.

I have thought about this since and will reveal my answer shortly, but before I do, we should pause for a moment to reflect on the process of medical education. I will refer here to natural selection as an analogue of this process, a concept that I have adapted from some ideas gleaned from David Dawkins and Susan Blackmore.

Darwinian natural selection is based on the concept that replicators (eg genes, viruses, prions) compete for their locus based on the phenotype produced. In the case of genes, these replications are done with high fidelity, but not perfectly, so that there are a few imperfect copies (mutations) produced, such that there are alternative genes meant for the same chromosomal locus (alleles). It is the competition among the alternative alleles, measured by their phenotypic expression that is the basis of natural selection. This process accounts for all of the dramatic variation seen in nature, including the present state of the information processing hardware (the brain), but it does not account for more rapidly changing behaviors and beliefs (cultures).