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Above the Fold

Atul Gawande and the Art of Medical Writing

Aug 15, 2010• 13

By BOB WACHTER, MD

Don’t read this.

That is, if you have a limited amount of time for reading today, I’d rather you read Atul Gawande’s essay on end-of-life care in this month’s New Yorker than this blog.

But if you can spare a little time, I’ll be focusing on some of the techniques Gawande uses to make his writing so lyrical and memorable. Whether you write yourself or limit your storytelling to cocktail parties and presenting H&P’s on morning rounds, lessons abound. Here are a few, gleaned from this month’s piece, “Letting Go: What Should Medicine Do When It Can’t Save Your Life?”:Continue reading…

Will Comparative Effectiveness Research Really Make a Difference If the Public Doesn’t Want It?

Aug 13, 2010• 8

By KENT BOTTLES, MD

Not long ago I was lucky to be invited to a New England Healthcare Institute discussion entitled “From Evidence to Practice: Making Comparative Effectiveness Research Findings Work for Providers and Patients “ in Washington, DC.

How to disseminate and implement Comparative Effectiveness Research (CER) so that patient care is really improved was the first topic tackled by the expert panel and the moderator, Clifford Goodman of The Lewin Group.

The target audiences for CER findings include: patients, disabled patients, providers, policy makers, health plans, medical device companies, pharmaceutical companies, hospital administrators, academic researchers, community physicians, professional societies, and regulators.

Michael McGinnis, MD, of the Institute of Medicine, offered clusters as a way to organize these different targets: Cluster 1 (patients, providers, policy makers), Cluster 2 (control levers like payers, purchasers, system managers, professional societies, regulators) and Cluster 3 (researchers and those concerned with methodology).

Seth Frazier, Vice President of Transformation at Geisinger, was the first of many to point out the gap between the academic literature of CER and what patients and providers need at the point of care. He noted that providers need actionable recommendations that can be integrated into the flow of the clinic and hospital and that much of the evidence-based medicine product is not usable in this practical way. This observation reminded me of the gap between the public and the health care experts that Drew Altman of the Kaiser Family Foundation documented so effectively and the Kristen Carmen Health Affairs survey that said patients regard evidence-based medicine as a barrier to what they want.

Imperfect Timing, Interesting Findings

Aug 13, 2010• 4

By ROGER COLLIER

I’ve been reading a recent paper from the Committee for Economic Development, one of the less doctrinaire business research groups, that should give health care reform advocates (and opponents) food for thought.

“ Health Care in California and National Health Reform,” authored by health care economist Alain Enthoven and CED’s Joseph Minarik, was apparently written during the course of the lengthy debate on reform, with updates inserted after passage of PPACA. With an emphasis on CED’s own earlier proposals for reform rather than the new law, the timing of the paper’s publication was obviously less than perfect, but, even so, the findings are well worth examining.

The paper’s scope is limited to California, clearly not a typical state, given its considerable HMO enrollment and relatively low per capita health care spending, but one with the largest non-federal employer insurance exchange (CalPERS, the state employee benefit system), and the largest delivery system HMO (Kaiser), both of which have made great efforts to make health care more cost-effective. The paper includes reports of interviews with CalPERS administrators and employee benefits managers of major academic and business employers offering a range of health care coverage options to their employees, including a number who have adopted a managed competition model with fixed dollar employer contributions and choice of coverage from among a limited number of competing options.

There’s both good and bad news for health care reformers.Continue reading…

No One Is Perfect, Not Even Computers

Aug 12, 2010• 17

By HERBERT MATHEWSON

My last post described how a precisely regimented dosage of intravenous medication delivered to me over six hours by a state-of-the art computer actually depended on the existence (and the survival for 6 hours) of a handwritten yellow Stickie hanging on my IV pole. I write this post as a recipient, certainly not a victim, since no harm occurred, of a “care error” caused by a computer.

After my first infusion I grumbled to my physician that it had taken 6 hours, and that the package stuffer the nurse gave me recommended about a 2 hour infusion for someone my weight and age. He was surprised but responded, “Those nurses are really good. They probably have more information about the drug. I would go with what they say.” So I called the Head Nurse in the Infusion Center. She told me that the infusion rates come from the computer. “How does the computer know them?”, I asked. She responded, “The Hospital Pharmacy Committee puts them in.” I called the Chief Pharmacist, noted the difference between the package insert and the computer recommendations, and asked him to review the information because I would sure like to spend just 2 hours off my boat rather than 6 for the next treatment. He contacted me a couple of days later to tell me that that medication infusion rate had been entered into the computer several years ago and was based on data from the one manufacturer of the medication. “There are now three manufacturers and two different concentrations. Each one has different infusion rates. Yours could go in over 2 hours. I will take care of updating the computer’s recommendations for your medication before the next treatment.”

Difficulties With Diagnosis

Aug 11, 2010• 5

By DAVID E. WILLIAMS

I’m impressed that the Boston Globe printed a number of insightful letters in response to its Mistakes that matter
article, which discussed the case of two patients whose prostate cancer
biopsies got mixed up. (One had cancer, the other didn’t. The one
without cancer got surgery as a result of the mixup, the one with
cancer had delayed treatment and possibly negative consequences as a
result.)

Two of the four letters are from patients who were tested for
cancer. The best is one from Irving Sacks of Peabody, documenting how
he searched widely for alternative treatments after being diagnosed
with cancer of the esophagus. In the end he found out from a medical
center in California that he had another condition –not cancer– and
didn’t need the proposed surgery to remove his esophagus. He says (and
I concur):

When confronted with a life-threatening
medical assessment, do not rely on a single diagnosis, and, when
getting a second opinion, go outside the network, even to another city.

Edgar Dworsky of Somerville wasn’t persuaded that he had prostate
cancer after the first pathologist said the slides were “suspicious for
cancer,” so he took the same slides to another pathologist who said he
“definitely” had prostate cancer and a third who said the slides were
“highly suspicious for prostate cancer.” Based on that set of findings
he’s decided he doesn’t (yet) have prostate cancer and has embarked on
a program of watchful waiting rather than active treatment. At least
from what he’s written it’s a little hard to follow his logic but for
his sake I hope he’s right.

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Aug 11, 2010

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Aug 10, 2010

Health 2.0 Northwest Chapter Kicks-off with a Big Bang

Aug 10, 2010• 2

The Health 2.0 Northwest Chapter is having its first meeting next week, and it’s a doozie. No starting off with a few drinks in a bar for these guys, they’ve got a serious host (the major Health Science University) and serious panelists. Congrats to Frank Ille at HealthSaaS and his crew for pulling this off, and kudos to our own (and Eugene, OR resident) Lizzie Dunklee for being on this high-powered panel. If you’re in Portland, you don't want to miss it

Date: Wednesday August 18 2010
Location: OHSU Old Library Auditorium
Time: Networking and snacks 5:00-6:00pm followed by Panel discussion 6:00-8:00pm

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Aug 10, 2010

Massachusetts Update

Aug 10, 2010• 29

By PAUL LEVY
Here is one of my occasional updates on theMassachusetts scene, for people looking for hints as to the kind of issues that might arise nationally as health care reform is implemented.

I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.Continue reading…