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Above the Fold

The Case For Traveling to the Center of Our Social Networks

May 23, 2014• 2

By JAMES FOWLER

Much has been made of David Lazer’s finding that Google’s Flu Trends tracker seriously missed the mark in its measurement of flu activity for 2012-2013—and in previous years, too.

For those who don’t know, Flu Trends monitors Google search behaviors to identify regions where searches related to flu-like symptoms are spiking.In spite of Flu Trend’s notable misstep, Lazer still believes in the power of marrying health and social data.

In discussing the results of his study, he has maintained Google Flu is “a terrific” idea—one that just needs some refining. I agree.And, earlier this month, Nicholas Christakis, several other colleagues, and I—with funding from the Robert Wood Johnson Foundation—published a new method offering one such refinement.

Our paper shows that, in a given social network (in this study’s case, Twitter), a sample of its most connected, central individuals can hold significant predictive power.

We call this potentially powerful group of individuals a “sensor group.”

By finding and monitoring the tweets of a sensor group, we can catch—and sometimes even predict—the outbreak of contagious information early on. That detection edge could improve how we track the outbreak of disease epidemics, the rise of certain terms or phrases, or shifts in political sentiment.

Whereas Flu Trends relies on a relatively static, proprietary “dictionary” of flu-related search terms based on average Google search habits, the sensor method taps into what is really happening in social networks in real time.

By drawing on language being used by a sensor group—such as mentions of an emergent symptom or a popular newly coined name for a disease—Google could gain insight into what their dictionary might be missing.Sampling both the average Googler’s behavior and that of the exceptionally connected social network user can paint a much fuller picture of whatever landscape we are interested in tracking. We can more accurately see how it looks now—and how it could look in the near future.

Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too ..

May 23, 2014• 19

By Elaine Khoong

“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.

We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.

What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.

Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.

Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.

I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?

The NFL’s Conflicted Relationship With Doctors

May 22, 2014• 6

By Arthur Caplan

Too often doctors, trainers and other health care professionals who work for professional sports teams are accountable only to their teams and, especially, team owners. To keep their jobs they have to keep coaches, general managers, fans and billionaire investors happy.

This situation has created an intolerable ethical mess in which athletes’ health is too often their lowest priority. It is time to fix that.

Concussions are giving professional football, hockey and other sports a huge headache these days. The implication is that the NFL, NHL and their doctors long knew that “getting your bell rung” was bad for an athlete’s brain but said nothing.

Now a group of former NFL players are suing the league claiming that they were given powerful painkillers and anti-inflammatory drugs to keep them on the field. They say no one ever warned them about the long-term dangers of addiction, horrible side-effects or playing injured while drugged to withstand pain.

The eight plaintiffs, led by 1985 Superbowl champions Richard Dent, Jim McMahon and Keith Van Horne, say the league “recklessly and negligently created and maintained a culture of drug misuse, substituting players’ health for profit.”

Team doctors and trainers “were handing out drugs like it was Halloween candy,” says the group’s attorney Steve Silverman. Among the drugs said to be given freely were Toradol, Percocet, Vicodin, Ambien, Prednisone and Lidocaine. The eight players estimate they were given “hundreds, if not thousands” of pills through the course of their careers.

None of this comes as a surprise to sports fans, especially those of a certain age, who remember the NFL, NHL, MLB, NASCAR, FIFA, pro cycling and NBA of the ’70s, ’80s and ’90s when doctors and trainers kept athletes going at any cost with any pill, salve, injection, bandage, device or inhaler they could get their hands on.

“Just win, baby” was the guiding ethical principle of the era and doctors and trainers put aside their oaths and codes to make sure stars played, their team won, the fans were happy and the owners renewed their contracts for another season.

A New Era in Value-Driven Pharmaceuticals

May 22, 2014• 3

By Leonard Kish & Cyndy Nayer

At the end of March the Amercian College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint statement saying they “will begin to include value assessments when developing guidelines and performance measures (for pharmaceuticals), in recognition of accelerating health care costs and the need for care to be of value to patients.”

You may have heard of value-based medicine, but are we entering a new era of value-based medications or value-driven pharma?

Price transparency is great, but it has be combined with efficacy to get to value (price for the amount of benefit). Medical groups are catching on to how important value assessments are, because if patients can’t afford their medication, they won’t take their medication, and that obviously can turn into poor outcomes.

Twenty-seven percent of American patients didn’t fill a prescription last year according to a Kaiser Family Foundation Survey. This trend seems likely to continue as we move toward higher-deductible plans, where those with insurance can have great difficulty affording medications.

Included in the ACC/AMA statement was a quote from Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine.

“There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed…These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources.”

Spreading risk and payment to different members of the health care value chain is beginning to make it apparent to more people and organizations that resources are finite. Patients and their physicians are starting to ask which treatments are worth the cost and have best likelihood of adherence.

An outgrowth of the move toward digital health and accountable care is that we’re entering every patient into a potential personal clinical trial with their data followed as a longitudinal study, and we can look much more closely at efficacy and adherence and reasons why it happens and why it doesn’t.

It won’t be long before we start to see comparative effectiveness across a variety of treatments and across a variety of populations. When we can connect outcomes data, interventions and costs all in the same picture we begin to see where the value (price against results) is and where it isn’t.

A Closer Look at Public Trust in Healthcare

May 22, 2014• 2

By PAUL KECKLEY

Public trust matters. It’s hard to build and easy to lose.

Of late, subpar performance has drawn public attention to a wide variety of industry notables:

General Motors agreed to a fine for malfunctions resulting in 24 recalls in recent years including 2.6M most recently with faulty ignition switches.
Security breaches in customer information at Target, Michaels and other retailers hurt sales and cost at least one CEO his job.
The Department of Veterans’ Affairs has been exposed to questions about its safety record, notably delays in treating veterans in its hospitals in 9 states.

Entire industries have seen their public trust erode as a result of misdeeds or self-inflicted wounds—the investment banking industry’s mortgage loan debacle, venerable news organizations from lack of objectivity, industrial food manufacturers from unhealthy supply chain management and so on. And industries like higher education and others face tough questions about their value proposition, as if decades of good will no longer matter.

In most cases, leaders of the most prominent organizations in these industries accept responsibility, appoint task forces to investigate and address their issues with the media and investors head-on. Their trade groups, likewise, announce new initiatives to restore public confidence. They hire professionals to bolster their influence. and in some cases, rebuild their reputation.

Public trust in industries matters as much as confidence in the individual companies and organizations themselves. An industry’s reputation and good will is always buoyed by the reputation of the companies that are its marque market leaders, and always at risk as a result of the misdeeds of any member, known or unknown.

By and large, excepting occasional drug manufacturing scares or recent well-publicized safety issues in a few of the 3000U.S. compounding pharmacies, our industry has remained virtually unscathed from the ever-more-skeptical public’s thirst for muckraking. The U.S. health system enjoys the confidence of the majority, especially older adults for whom it is always top of mind.

But the reality is this: the US health industry is susceptible to erosion of its public trust, not as a result of the Affordable Care Act nor political in fighting in Congress.

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

May 22, 2014• 38

By JAAN SIDOROV, MD

As your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital. Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.

Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command. If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing. Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain. A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.

“Good grief!” says your correspondent. Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

Because Cancer.

May 21, 2014

By “Knot Telling”

Do not tell me how to feel!

For those who may not read through to the end, here is the take home: you do not get to tell me how to feel or what my attitude should be, no matter who you are.

Sure, it’s more comfortable for me and the people around me when I’m have a positive attitude, but that does not mean that I have to live “all bliss all the time” like some insane American cable television station. Being positive does not mean pretending that nothing is wrong because… cancer, people!

A young woman who, I think, just turned twenty-two posted this on her Facebook page: “That’s the thing about pain. It demands to be felt.” She knows what she is talking about, by the way.

It does no good to pretend that emotional pain does not exist. It does no good to pretend that it’s not there. The only way I’ve ever found to get through pain is to recognize it, sit with it, walk through it to the other side. Sometimes that process leaks out into the environment and then I don’t smile prettily at everyone around me. Sometimes I’m snotty and bitchy and generally not one of Jesus’ little sunbeams. Sorry about that, but… cancer, people!

Here’s another news flash. A positive, determined attitude will not cure cancer, no matter what the popular media tell you. The following quotations are from the American Cancer Society:

In 2010, the largest and best-designed scientific study to date was published. It looked at nearly 60,000 people, who were followed over time for a minimum of 30 years. This careful study controlled for smoking, alcohol use, and other known cancer risk factors. The study showed no link between personality and overall cancer risk. There was also no link between personality traits and cancer survival.

[…]

Continue reading…

Scope of Practice: Playing at the Top of My License?

May 20, 2014• 25

By Karen S. Sibert, MD

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

Early ACA Data Shows No Wave of Sick Patients

May 19, 2014• 29

By JOSH GRAY & IYUE SUNG

Since launching ACAView, our joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth, in early April, open enrollment under the Affordable Care Act (ACA) has closed for 2014 and The White House has issued final numbers: eight million people enrolled through the marketplace and five million outside the marketplace. Add another three million enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the total number of people enrolled under the ACA’s individual mandate is close to 16 million.

Since some of these enrollees had previous forms of insurance coverage, it is important to estimate overall reductions in the number of uninsured. RAND estimates that 9.3 million more Americans have insurance in Q1 of 2014, compared to Q3 of 2013, but these figures exclude the surge of enrollments in the last half of March. The Congressional Budget Office (CBO) estimates 12 million net newly insured people through either the marketplace or Medicaid (including 1 million who lost insurance), but these estimates exclude enrollments outside the marketplace.

In short, “newly insured” and “enrollment numbers” are counted in different ways and can be confusing. But let’s conservatively assume that the number of net new insured individuals is roughly nine million, or 2.8% of the population. Are these new beneficiaries having a measurable impact on medical practices?Continue reading…

Developing Physician Culture in New Risk Models

May 18, 2014• 4

By Craig Tanio, MD

There is a saying that “culture eats strategy for lunch.” Never has this been truer than when looking at primary care or physician group delivery system innovation. Health care industry leaders must invest more time creating and scaling the right culture as they innovate.

There has been a great deal of controversy on the ability of the Primary Care Medical Home (PCMH) to impact total medical costs. Critics have noted that PCMH is adding additional costs to the structure without systematically demonstrating improvement in total costs and quality.

A great deal of time has been spent debating the proper structures, processes and financial incentives that are necessary to create value in physician-led-risk or shared-savings models. However, I suspect the real issue is that culture is a major driver of performance, and it has not been systematically measured or managed.

At ChenMed, we have developed a primary-care-led model focused on the care of seniors with multiple and chronic health conditions. Funded through full-risk arrangements with Medicare Advantage plans, we outlined an overview of the original Miami-based model in Health Affairs last year [1].

Over the last three years, we have scaled the model from five centers in Miami to 36 centers in eight markets in the Southeast and Midwest. This has required us to adjust our model in ways that allow it to readily scale. We have been able to make the fundamental economics work while rapidly scaling the medical practice, and are actively working on innovations to improve value every day.

One of the foundations of our strategy is getting the physician culture right. This is not easy to measure from a health services and policy research perspective.Yet, it matters a great deal from a practical and business perspective. McKinsey and Company has developed an influence model on how organizations create the right behavior and mindset shifts, which we have found useful [2].