May 26, 2009

More is not always better in medical imaging

Imaging Idolatry. That's what Dr. Rick Deyo describes in the Archives of Internal Medicine with a subhead of "The Uneasy Intersection of Patient Satisfaction, Quality of Care, and Overuse."

Background: "A 2008 report by the Government Accountability Office (GAO) noted that in just 7 years, from 2000 through 2006, Medicare spending for imaging more than doubled to approximately $14 billion. Most of the growth was in advanced imaging such as computed tomography (CT) and magnetic resonance (MR) imaging. In the particular case of lumbar spine imaging, MR images covered by Medicare increased 307% between 1994 and 2005. The GAO linked spending growth, in part, to a shift of more advanced imaging from hospitals into physician offices. It also noted wide geographic variability in the use of imaging, "suggesting that not all utilization was necessary or appropriate."

And outcomes aren't necessarily improved by more imaging.

Key points from Deyo's summary:

• Just because patients want imaging doesn't mean it's good medicine. Deyo writes: "First, it seems unwise to equate patient satisfaction with better health outcomes, and satisfaction-based incentives may foster overuse. Second, it may be necessary to redouble our efforts at patient education. There is at least a shred of evidence that brief patient education can help to maintain patient satisfaction when imaging is not recommended. Avoiding imaging may itself be part of this education: when radiography was performed for low-risk patients with back pain, expectations for imaging increased. In essence, performing imaging may teach patients that it should be expected. Finally, if quality of care is defined in part by avoiding overuse, we have a challenging task that may require more innovative strategies. That task is to convince our patients that more is not always better."

Posted by schwitz at 8:29 AM | Comments (3)
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April 2, 2009

Disconnect between supply and patient needs

A new Dartmouth Atlas report, "The Hospital and Physician Capacity Update," shows that "the supply of hospital beds and doctors varies widely from region to region across the United States, and the variations have nothing to do with the level of care patients want or need."

From a Dartmouth news release:

One example that illustrates the large variations: San Mateo and San Luis Obispo—both in California—had 1.45 beds per 1,000 residents in 2006, while Mississippi’s Jackson and Gulfport both had triple that number, 4.44 beds per thousand.

The distribution of hospital capacity fails to reflect the regional need for hospital care, either for beds or for hospital staff. As the health reform debate heats up, the report’s lead author, David Goodman, M.D., M.S., professor of pediatrics and community & family medicine at The Dartmouth Institute for Health Policy and Clinical Practice, said it is important to understand the disconnect between the supply of hospital beds and patient needs.

“Simply put, a built bed is a filled bed,” says Goodman. “While high hospital and physician capacity drives costs upwards, there are many regions that do well with many fewer beds and physicians per capita. Health systems in these lower capacity regions show that efficiency is a partner, not a competitor, of quality."

Posted by schwitz at 10:12 AM | Comments (1)
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September 26, 2008

Chicago Tribune's "United States of Anxiety" series

The Chicago Tribune, in the middle of a good story with a catchy headline - "The United States of Anxiety: Worried Sick Over Our Health Care" - includes some vital messages:

"Polls show voters worry a lot about health care and how much they spend on it. Presidential candidates John McCain and Barack Obama have responded by peddling plans they claim will help more Americans attain and afford care.

But neither candidate has focused publicly on treating the real problem: why American medical care costs too much and isn't as good as it should be.

We waste money on tests and visits to specialists that don't make us better. We spend big to add a few weeks or months to the inevitable end of a dying patient's life. We use expensive technology at any cost, even when it exceeds our needs, and we fail to encourage simple, proactive steps that would keep us healthier and save us money. We often don't know which treatments work the best, so we err on the side of too much care, for too much cost, with sometimes damaging consequences.

As a result, Americans pay significantly more for medical care than anyone else in the industrialized world. Every year, we spend a bigger chunk of our family budget on doctor bills, hospital stays and prescription drugs. Yet we trail several other nations in health-care quality, access and efficiency.

Most Americans have long assumed that more is better when it comes to their health: more doctors, more tests, more hospital time. But a decade of comprehensive studies suggests that all those visits and tests and hospital stays are often a waste of money—and sometimes a drag on our well-being."

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July 18, 2008

U.S. health system on the wrong track

In an announcement that got surprisingly little news attention, the Commonwealth Fund released its National Scorecard on U.S. Health System Performance, 2008. Excerpts: 693970.jpg

"The U.S. health system is on the wrong track. Overall, performance has not improved since the first National Scorecard was issued in 2006. Of greatest concern, access to health care has significantly declined. As of 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured during the year or underinsured, up from 35 percent in 2003. At the same time, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th as other countries raised the bar on performance. Up to 101,000 fewer people would die prematurely if the U.S. could achieve leading, benchmark country rates. ...

The U.S. spends twice per capita what other major industrialized countries spend on health care, and costs continue to rise faster than income. We are headed toward $1 of every $5 of national income going toward health care. We should expect a better return on this investment. ...

National leadership is urgently needed to yield greater value for the resources devoted to health care."

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June 1, 2008

Connecting the dots in health care reform news

As we flip the calendar over from a very busy May into a sunny June, I want to reflect on the common themes in the blog entries of the past four days:

1. My PLoS Medicine article, “How Do US Journalists Cover Treatments, Tests, Products and Procedures? An Evaluation of 500 Stories.?

2. The Commonwealth Fund analysis on variations in child health care across the US.

3. Another "more care isn't always better care" study - this time in JAMA.

4. Consumer Reports releasing an online tool using Dartmouth Atlas data to allow you to look at aggressive vs. conservative care - comparing hospitals on this scale.

Connect the dots. Jack Wennberg's work rings through these themes.

Inexplicably widespread variations exist in the way health care is practiced in this country and more data comes in every day. More evidence also comes in every day that "more and newer isn't always better" in health care. And journalists are spending too much time on the "more" and the "newer" rather than on questions of evidence, costs, quality and access to care.

As a result, many consumers aren't getting much smarter at a time when some policymakers, employers and insurance company marketing folks push "consumer-driven health care" plans. Americans don't know what they're buying with the health care dollar and giving them more "skin in the game" doesn't make them smarter - only makes them hurt more - if they're not educated in the dots.

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May 31, 2008

Consumer Reports' tool on hospital aggressiveness

Consumer Reports this week launched a new online "compare your hospital" tool. CR states:

"The data you'll see here, from The Dartmouth Atlas of Health Care, shows that not every hospital practices conservative care. Many patients with these long-term serious illnesses are repeatedly hospitalized and seen by many different physicians. The Dartmouth research has shown that aggressive care does not necessarily improve patient outcomes and can sometimes shorten life. That's because it exposes people to a greater risk of hospital-acquired infections and the medical errors that can occur when too many doctors test and treat patients in an uncoordinated way.

It's important to understand that the distinction between aggressive and conservative care does not apply to medical emergencies such as a heart attack, stroke, broken hip, or inflamed appendix. All hospitals everywhere address these conditions immediately and with the full arsenal of treatments at their command."

See how a Seattle newspaper localized the story. Nice job.

Posted by schwitz at 9:12 AM | Comments (1)
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May 30, 2008

More care is not always better care

While I had my own journal article published this week, my good friend and mentor Jack Fowler had an important paper, "Relationship Between Regional Per Capita Medicare Expenditures and Patient Perceptions of Quality of Care," published in JAMA.

A blog on boston.com summarized the paper as follows:

More isn't necessarily better when it comes to medical care, a survey of Medicare patients shows.

Spending on healthcare varies widely across the United States, from $12,000 a year for Miami beneficiaries to $5,700 for comparable care in Minneapolis, previous studies have shown. But research led by Floyd J. Fowler of the University of Massachusetts-Boston shows that money spent on medical care didn't necessarily match perceptions of the quality of that care.

More than 2,000 Medicare patients around the country were asked by phone and mailed questionnaire whether their needs were met, what they thought about the quality of their care as outpatients, and how they would rate their overall medical care.

People living in high-expenditure areas got more medical care than those living in lower-cost areas, judged by such measures as physician visits and cardiac tests. But when asked how they felt about their treatment, more patients living in lower-expenditure areas gave their quality of care top marks (9 or 10 on a scale of 0 to 10) than their peers in the high-priced parts of the country, by a margin of 63.3 percent compared to 55.4 percent.

"The results taken together document that spending more on medical care does not improve patient�s perceptions of the medical care they receive," the authors write.


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April 14, 2008

The myth of "the best health care in the world"

Monday morning catchup....

Newsweek, two weeks ago, published a column, "The Myth of 'Best in the World'."

Excerpt:

"Not to be heartless or anything, but let's leave aside the dead babies. In international comparisons of health care, the infant mortality rate is a crucial indicator of a nation's standing, and the United States' position at No. 28, with seven per 1,000 live births—worse than Portugal, Greece, the Czech Republic, Northern Ireland and 23 other nations not exactly known for cutting-edge medical science—is a tragedy and an embarrassment. Much of the blame for this abysmal showing, however, goes to socioeconomic factors: poor, uninsured women failing to get prenatal care or engaging in behaviors (smoking, using illegal drugs, becoming pregnant as a teen) that put fetuses' and babies' lives at risk. You can look at 28th place and say, yes, it's terrible, but it doesn't apply to my part of the health-care system—the one for the non-poor insured.

That, in a nutshell, is why support for health-care reform is fragile and shallow. Yes, many people of goodwill support extending coverage to the 47 million Americans who, according to the Census Bureau, had no insurance for all or part of 2006. An awful lot of the insured, though, worry that messing with the system to bring about universal coverage, even if it allows more newborns to survive, might also hurt the quality and availability of care that they themselves get ("If I have trouble getting my doctor to see me now, what will happen when 47 million more people want appointments?"). This is where you start getting the requisite genuflection to the United States' having "the best health care in the world." One problem: a spate of new research shows the United States well behind other developed countries on measures from cancer survival to diabetes care that cannot entirely be blamed on the rich-poor or insured-uninsured gulf. None of this implies a specific fix for the U.S. health-care system. It does, however, say that "the best in the world" is a myth that should not be an impediment to reform."

Posted by schwitz at 7:42 AM | Comments (0)
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October 24, 2007

The Dangers of a "Zagat Guide" to Physicians

Read Maggie Mahar's essay on her HealthBeat Blog.

It's about how physician ratings services that look only at "trust, communication, availability, and environment" but fail to measure quality of care and health outcomes are not exactly what the patient ordered - or needs.

She concludes:

"A more credible version of what the Zagat system purports to be—a system that empowers patients to understand and manage their relationship to doctors—is the paradigm of shared decision-making.

Very briefly let me just say that: “shared decision making? is a process which allows doctor and patient to share valuable information. First, the doctor describes the relevant risks and benefits of all treatment alternatives, and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others. Numerous studies indicate that when patients have the opportunity to participate in medical decision making with their physician, the patient-physician dialogue improves, and patient well-being improves as well.

This is the real deal when it comes to empowering patients to take control of their “health care decision making.? Presumably a doctor who engages in shared decision making will score high on the metrics of trust and communication—no conflict there.

But from a long-term perspective, the reduction of medical care to Zagat snippets may be counter-productive with regards to moving toward shared decision making, because it reinforces the notion of health care as consumption. Treating doctors like restaurants perpetuates the notion that health care is like any other commodity: we want it fast and we want it now. In reality, real empowerment demands active engagement and a certain measure of personal responsibility.

The danger is that in relying on superficial measurements of service, patients will get comfortable with the quick fix approach, and we take two steps back with regards to truly integrating patients into health care as active participants."

Posted by schwitz at 8:45 AM | Comments (0)
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August 21, 2006

Ballooning rates of balloon procedure in one Ohio town

The New York Times published a story showing the questionable variation in health care, "Heart procedure is off the charts in an Ohio city."

Elyria, Ohio does coronary angioplasties (often including the use of drug-coated stents to keep arteries open) at four times the national average, three times the rate of Cleveland, just 30 miles away.

This was all found through the valuable Dartmouth Atlas project, which, according to the Times, "also shows that the Elyria doctors have a higher than average tendency to perform diagnostic coronary angiographies on patients — the primary test that is used to detect blockages in the first place. 'People are just geared to be looking at things, and they find them,' said Dr. John E. Wennberg, who pioneered the Dartmouth data analysis."

The Times story concludes: " In the absence of any real monitoring or oversight, doctors in most places, including Elyria, have few incentives not to favor the treatments that provide them the most reimbursement. (A) San Francisco cardiologist said that the way physicians are typically paid — more money for more procedures — results in too many decisions to give a patient a stent.

'You can’t be paying people large sums of money to do things without checks and balances,' he said."

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July 10, 2006

Big provider pays big bucks for unnecessary surgery

Jeanne Lenzer reports in this week's BMJ: "The second largest health provider in the United States, Tenet Healthcare, has agreed to pay nearly $500 million to settle claims that doctors did unnecessary surgery at the Redding Hospital, in Redding, California.

The hospital was raided by 40 agents from the Federal Bureau of Investigation in 2002 after it received reports that doctors were performing numerous unnecessary cardiac operations. The settlement was signed on 14 June and is the largest ever for unnecessary procedures and ends all civil and criminal actions arising out of the allegations.

In a separate settlement on 29 June, Tenet agreed to sell 11 hospitals and pay $900m to resolve charges that they overcharged Medicare $1.5bn."

Posted by schwitz at 9:31 AM | Comments (0)
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June 29, 2006

Important questions about medical errors study

Don Berwick and the Institute for Healthcare Improvement have done important work in addressing health care quality issues. But they may have overstepped the boundaries of evidence with a recent study that drew a lot of news coverage, claiming that hospitals they worked with saved over 122,000 lives by cutting down on errors and improving care.

"The Numbers Guy" column by Carl Bialik in the Wall Street Journal says the studies warrant a second opinion. Bialik quotes Dr. Bob Wachter of UCSF, author and lecturer on medical errors: ""I don't think it saved 122,300." He added that, like in a political campaign, the health-care campaign used "statistics selectively to try to mobilize your base to do good. It's understandable. It's not good science."

Dr. Gil Welch of Dartmouth and the VA said, "I think there's been a tendency in the errors business to first overstate the size of the problem, and now, I'm afraid, to overstate the effect of interventions on the other side."

Read Bialik's full article. It does a good job of questioning claims and pointing out how well-intentioned advocates may be driven by passion more than by evidence, and how journalists can easily get sucked into the vortex. (Bialik points out how the Wall Street Journal reported the Berwick claims, along with the Associated Press, U.S. News & World Report and many other media.)

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July 21, 2005

Wide variations in U.S. hospital quality

"Geography is destiny in health care," says Dartmouth's Jack Wennberg.

It's seen again in two studies in this week's New England Journal of Medicine.

The studies show general improvement among U.S. hospitals in improving their quality of the care, but that too many even top performers fail too often to offer the right treatments following clearly established evidence.

The Washington Post quotes Harvard's medical quality expert Lucian Leape: "What's going on here? These are treatments that are no-brainers. These are the easy things," said Leape. "We're really looking at patients for whom 100 percent should be receiving these treatments. So why isn't it 100 percent?"

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