Recently in Quality of care Category

Have MRI, will do back surgery

From MedPageToday:

Patients with low back pain are more likely to have surgery if they live in an area with more magnetic resonance imaging (MRI) machines, researchers say. ...Yet studies show increased surgery rates don't necessarily improve outcomes, as MRIs may also detect anomalies unrelated to back pain, they said.

Poor service, irregular quality, at astonishingly high cost

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That's the American health care industry, as described by The Atlantic in its introduction to David Goldhill's story, "How American Health Care Killed My Father."

It's difficult to choose one worthy excerpt of this fine piece, but I chose this one:

How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient's room? Considering the importance of a patient's frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient's care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

I'm a businessman, and in no sense a health-care expert. But the persistence of bad industry practices--from long lines at the doctor's office to ever-rising prices to astonishing numbers of preventable deaths--seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results--a reason my father and so many others are unnecessarily killed.

Read the entire story.

Instead of all of those stories about blue M&Ms for spinal cord repair, journalists should be spending more time addressing the kinds of issues Ford Vox does on Excerpts:

If Congress passes Barack Obama's healthcare plan, the Affordable Health Choices Act, states will lose a lot of their influence over healthcare administration and adjudication. Doctors across the country are outraged, invoking the specter of Big Brother and socialism. I on the other hand call the president's plan progress. If it passes, it will lead to a greater equality and a higher quality of healthcare for patients nationwide.

Let me explain. In the medical field called Physical Medicine and Rehabilitation, I work as part of a team trying to put lives back together after disabling injury and disease. We've got a Rolodex of world-class colleagues in all the specialties you'll need at my medical center. But if you're struck by a calamity sufficient enough to enter our care here in St. Louis, I hope you don't live in Missouri. You're much better off being one of my patients from the other side of the river in Illinois.

That's because there's a desperate truth lurking behind our efforts in rehabilitation medicine. Unless our intricate plan of family assistance and state services works out just so, many of our patients are at risk of becoming homeless or permanently shuttled off to a nursing home. In 2005, Missouri's then-Gov. Matt Blunt slashed Medicaid, the federally mandated, state-run insurance designed for poor families. We see a lot of Medicaid in rehabilitation, thanks to young invincibles who meet their match, and those with brewing problems that go untreated for too long for lack of insurability or a good job. Think you'll never need Medicaid? I've seen brand-name private insurance exsanguinate by the first week of rehab, leaving young professionals with nothing more than Medicaid.

And if you've got a new spinal cord injury and we've taught you to catheterize yourself, good luck getting those catheters if you're on Medicaid. Medicaid will cover the antibiotics for the urinary tract infections you'll acquire from recycling your only catheter and the urologic interventions you'll need to remove bladder stones. If your kidneys fail altogether, the federal government will step in with dialysis. And if your electric wheelchair breaks down or needs a new battery, we'll have no problem moving you into a nursing home. You'd prefer a new battery so you can continue living at home? You picked the wrong state.

As a poor Missourian, you'll have no more than 30 days for your rehabilitation. Not quite ready to go home? Need a few more days of intensive therapy? Again, you picked the wrong state. ...

With comprehensive national standards, states will not be able to dodge their responsibilities. Their disparate health insurance regulations and Medicaid administrations will no longer trample basic human rights. So let's stop what doesn't work and go forward together.

Exploring the harmful effects of health care

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A commentary in the current issue of JAMA uses that headline to open a discussion about how "it is time to address the possibility of net health harm by elucidating more fully aggregate health benefits and harms of current health care."

Excerpts and bullet points from the commentary:

  • Unlike health, health care is not an unalloyed good.

  • Determinants of well-being transcend health care.

  • Harm may occur as a direct or indirect consequence of health care. Direct harm includes adverse physical and emotional effects, generally to individuals, as a by-product of health care delivery. Indirect harm is a collateral effect on individuals and communities not directly involved in care. Indirect harm is closely associated with excess health care costs, which may induce harm by competing with other health-producing services.

  • Physical harm is a by-product of routine care processes. Some aspects of physical harm (eg, adverse drug effects and medical errors) are better known than others (eg, untoward effects of radiation from computed tomography). Although physical harm is an accepted risk of treatment with increasingly powerful medications and interventions, much consequent harm is avoidable when treatments are overused or used without sufficient evidence of effectiveness.

  • Some overtreatment happens when physicians lack evidence about the ineffectiveness or risks of a treatment.

  • Percutaneous coronary intervention (angioplasty, stents, etc.) is likely being overused in the Medicare population. Contrary to national guidelines, more than half of Medicare patients with stable coronary disease lack noninvasive documentation of ischemia before elective percutaneous coronary intervention.

  • End-of-life care provides another example of medical excess. One study found that only 30% of hospitalized patients older than 80 years wanted care to prolong life, but 63% received life-prolonging care such as intensive care unit admissions, intubation, surgery, and dialysis. Wide variation exists in end-of-life care.

  • Although the potential for harm is substantial, both physicians and patients generally embrace technology enthusiastically--implicitly trusting in its benefit before adequate assessment is made.

  • Unnecessary care can also cause emotional harm, including anxiety from testing or treatment and from creating inappropriate expectations. Emotional harm, although less well studied than physical harm, has important effects on patient well-being.

  • A diagnosis of hypertension made through screening resulted in more office visits and sick role behavior without improved medication adherence or blood pressure control. Spinal magnetic resonance imaging often reveals alarming but clinically irrelevant findings, and adults with back pain who receive magnetic resonance imaging results may experience worse dysfunction than those not given the results. Likewise, many unproven screenings, such as the prostate-specific antigen test, remain commonly used; although relatively inexpensive and often sought by patients, they are unlikely to help and may induce harm, including anxiety associated with false-positive results. Exaggerated fears and "medicalizing" normal phenomena are as harmful as unrealistic expectations and are fostered frequently by marketing hype and sometimes inadvertently by health care clinicians.

  • Although health care's objective should be to improve health, its primary emphasis has been on producing services.

  • The possibility that health care might cause net harm is increasingly important given the sheer magnitude of the modern health care enterprise.

It's a thoughtful commentary. Read the entire piece if you have the chance (although it requires a JAMA subscription).

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."

Disconnect between supply and patient needs

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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."

Chicago Tribune's "United States of Anxiety" series

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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."

U.S. health system on the wrong track

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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."

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.

Consumer Reports' tool on hospital aggressiveness

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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.

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 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.

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'."


"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."

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."

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."

About this Archive

This page is an archive of recent entries in the Quality of care category.

Politics & health is the previous category.

Risk communication is the next category.

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