KQED, local PBS in San Francisco writes to tell me that a new series of Truly CA is beginning Sunday, May 16 at 6pm on KQED Public Television 9. The independent documentary series about life in the Golden State kicks off its sixth season with Firestorm, a timely film about the role firefighters play in the current medical system. The film coincides with the first day of National EMS Week (May 16-22, 2010).
Above the Fold
A Health Affairs collection
Anyone interested in taking possession of a complete set of Health Affairs dating back to 2003 and before? A friend of mine is getting rid of them. This is in the SF Bay Area. *******@*********lt.net” target=”_blank”>Email me if you’re interested.
Badness in Baltimore: Can Peer Review Catch Rogue Doctors?
By BOB WACHTER, MD
A couple of months ago, a Baltimore reporter called to get my take on a scandal at St. Joseph’s Hospital in Towson, an upscale suburb. A rainmaker cardiologist there, Dr. Mark Midei, had been accused of placing more than 500 stents in patients who didn’t need them, justifying the procedures by purposely misreading cath films. In several of the cases, Midei allegedly read a 90 percent coronary stenosis when the actual blockage was trivial – more like 10 percent.
Disgusting, I thought… if the reports are true, they should lock this guy in jail and throw away the key. After all, the victims now have permanent foreign bodies in their vascular beds, and both the stent and the accompanying blood thinners confer a substantial lifetime risk of morbidity and mortality. As I felt my own blood beginning to boil, the reporter asked a question that threw me back on my heels.
“Why didn’t peer review catch this?” he asked.
Hospital peer review is getting better, partly driven by more aggressive accreditation standards for medical staff privileging. In my role as chief of the medical service at UCSF Medical Center, I’m now expected to monitor a series of signals looking for problem doctors: low procedural volumes, unusual numbers of complications, and frequent patient complaints, unexpected deaths, and malpractice suits. When a flashing red light goes off, my next step is to commission a focused review of the physician’s practice. The process remains far from perfect, but it is an improvement over the traditional system, in which docs tapped a couple of their golfing buddies to vouch for their competence.Continue reading…
Worth It
By ROB LAMBERTS MD
I saw the note on the patient’s chart before I opened the door: “patient is upset that he had to come in.”
I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression. I barely recognized him, having only seen him a handful of times over the past few years. Scrawled on the patient history sheet in the space for the reason for his visits were the words: “Because I was forced to come in.”
By stomach churned. I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol – both treated with medications. He was last in my office in November…of 2008. I blinked, looked up at his scowling face, and frowned back. ”You haven’t been in the office for over eighteen months. It was really time for you to come in,” I said, trying to remain calm as I spoke.
If I Were as Sexy as Atul Gawande
While I don’t much feel sorry for myself these days (I used to, but that was years ago now), I had a recent pang of it reading Atul Gawande’s new book The Checklist Manifesto.
In this bestseller, he points out that much of what ails us in health care is the lack of good checklists. Not just the lists of course, but the fact that much of health care is now rote stuff that we already know how to do. What we need to do is accept that and stop treating the work like it’s a craft-brewed, once-in-a-lifetime invention. We need to start treating it like a complex set of tasks that needs to be done well, in order, every time and preferably by technicians specially trained to repeat the list. This Gawande guy is so smart, good-looking and bloody silver-tongued, that he gets to saunter out with what athenahealth has been trying to say and do for the last decade—only he gets published right off! I just know he’s gonna get one of those ooey gooey softball interviews with Terry Gross and even get to meet Obama over it. I feel like the guy on the FedEx commercial who didn’t get credit for the idea because he didn’t “go like this —” when he offered it.
Statistics – Using the Truth to Mislead
My daughter is an accountant. She took a statistics class in high school, and another as a requirement for her major. My son has taken a statistics course, and he is an English Literature major. I was a chemistry major in college and have an an MD and have never taken a statistics course. I don’t even recall a lecture on statistics in medical school. Mark Twain quoted Disraili as saying, “There are three kinds of lies: lies, damned lies and statistics.” Reading medical journal articles reporting on the benefits and lack of benefits when reported statistically can be really challenging. Reading a report of these, or worse listening to an interested party, like a sales rep or sponsored speaker talk about a study, requires being a skeptic. Here are some examples of how true statistics can be worse than a lie, and how what would seem to be common sense does not pay off.
Half full. Half empty.
By PAUL LEVY
At a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.
To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)
The Practical Consumer vs. The Illogical Deb Peel
By
So it’s time for a little rant about everyone’s favorite privacy advocate, and the way she gets treated in the press—including by people who should know better (yes, I mean you, Inga at HERTalk, even though I am your favorite booth babe). I won’t overdo my previous statements about the illogical inconsistencies of Peel’s positions, and more to the point the utter one-sidedness of the utility of only caring about privacy breeches and nothing else. But it is time to remind everyone who’s rational and who’s the fruit loop.
Three different articles in recent days brought this up. Xconomy (the TechCrunch of Boston) had a long article about new “ich bin keine blogger” and modern linguist Jonathan Bush (CEO, athenahealth). In a good article, mostly about how athenahealth was spending more money on marketing and therefore making lower profits, Ryan McBride had a throwaway para at the end about a new athenahealth (still-under-wraps-and-likely-to-stay-there-for-a-while) product called athenacommunity. Here’s the offending para (and note that McBride annoys the athena PR gods by using a capital A when the name is lowercase!):
Athena might be able to halve the amount that physicians pay to use its EHR if they participate in what is now a nascent effort at the company called “AthenaCommunity.” Athena’s EHR customers who opt to share their patients’ data with other providers would pay a discounted rate to use Athena’s health record software. Athena would be able to make money with the patient data by charging, say, a hospital a small fee to access a patient’s insurance and medical information from Athena’s network. For a hospital’s part, this might be cheaper than paying its own staff to gather a patient’s information through standard intake procedures. Hallock, Athena’s spokesman, says the community is in development and is slated to launch later this year
Inga at HERTalk spied an opportunity to get Deb Peel some rant time. And based on that one snippet Peel went off:
When Medicare “Cuts” are Medicare “Savings”
In a post titled “Slowing Down that Revolving Readmissions Door” the New America Foundation’s Joanne Kenen writes about avoidable readmissions. “I once interviewed a patient who literally could not remember how often he had been hospitalized within just a few months,” Kenen recalls, referring to a story published in the Washington Post last year.
There, she reported that “one of five Medicare hospital patients returns to the hospital within 30 days–at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks.” Within a year, two out of three are back in the hospital—or dead—says Jencks who consults on this issue for the Institute for Healthcare Improvement (IHI).
This is money that health care reformers could use as we expand care to the uninsured. It’s worth noting that what many call “Medicare cuts” are really “Medicare savings”—billions that could be reclaimed if we rescued patients from that revolving door.
Under reform legislation, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced, beginning in 2011. I would guess that some private insurers will follow Medicare’s lead.
A 21st Century Health Care Roadmap: The Path from Peril to Progress
By SUSAN BLUMENTHAL, MD and DENIS CORTESE, MD
A Commission of national health care experts convened by the Center for the Study of the Presidency and Congress (CSPC) has unveiled a roadmap and integrated approach that will help to put “health” back into our nation’s health care system as well as address key opportunities following passage of health care reform legislation.
The CSPC Commission on U.S. Federal Leadership in Health and Medicine: Charting Future Directions is releasing its second report, A 21st Century Roadmap for Advancing America’s Health: The Path from Peril to Progress, emphasizing a comprehensive spectrum of actions to build a 21st century system that will make America the healthiest nation in the world. Already, the CSPC Health Commission’s proposals have helped shape new Federal initiatives and are reflected in recent health reform legislation.
Now that historic health care reform legislation has been passed, it is critical to examine the next steps necessary to ensure that all Americans gain maximum value out of our current health care system, and that all of the key elements necessary to improve the health of the nation are addressed. While the United States spends over 17 percent of GDP on health care—nearly twice as much as any other nation—it ranks only 49th on life expectancy, and Americans get the right treatment just 55 percent of the time.
