Quality

The Dartmouth Atlas has long made a mission of pointing out the variation in medical practice across the US, and in the process, the Atlas has gained a reputation for innovative, incisive research. Among health policy geeks, its maps are legendary.

That explains the general dismay over “After Hospitalization,”  the most recent Atlas report, which came out last Wednesday. According to the report, the hospital community has done a lousy job of making sure patients don’t land right back in a hospital bed after they’re discharged. Preventable readmissions are recognized as a serious problem, taking patients out of their homes and costing billions of dollars each year. Medicare has decided to link hospital payments to success in meeting a readmission standard, and that means a lot of hospitals have a big problem according to the Dartmouth Atlas.

Efforts to reduce readmissions thus far have sputtered. According to the Dartmouth report, surgical and medical readmission rates between 2004 and 2009 were essentially constant. Poor coordination of care between hospitals and post-hospital recovery are the primary reason for readmissions. When chronically ill patients leave the hospital, their medical needs are often far from complete—they require medication, follow-up, and management over an extended period. Even knowing that, many patients still don’t see a primary care doctor within two weeks of their discharge—a step that Dartmouth and others see as crucial to proper care management.

Health Wonk Review, Muppet Edition!

Hello all, and welcome to another exciting episode of Health Wonk Review! (Regular readers will note that yes, I used line last time. I have half a mind to make Alistair Cookie the official HWR mascot, here at New Health Dialogue.) In honor of what would have been Jim Henson’s 75^th birthday last week, I bring you the Muppet Edition of Health Wonk Review!

Now, without further silliness, the articles!

Quality Care

Here at New Health Dialogue, we’re exulting in doctors’ acceptance that yes, they do overtreat patients! Now, getting them to accept that money is part of the reason why…

Jonena Relth of Healthcare Talent Transformation draws attention to the cool new physician payment system being tried at Fairview clinics in Minnesota: payments are based on patient satisfaction and health, rather than by the number services provided.

David Williams draws a parallel between diagnosis and management consulting: experienced clinicians need to be wary of “early closure,” and avoid becoming like the “more experienced managers [who] are satisfied with two data points – after all, that’s enough to make a line, [or the partners who] just need one data point – they can assume the slope.”

Jessie Gruman, at the Prepared Patient Forum, wonders if the collaboration between HHS, the Robert Wood Johnson Foundation, Dr. Oz, and others will help Americans learn to pay attention to their medical care and improve communication with their providers.

Chris Langston points out that there are fewer people entering training for geriatric specialties—a workforce that may be critical in addressing the communications issue Jessie discussed.

The most recent issue of the Archives of Internal Medicine includes a provocative survey of primary care physicians—one that indicates a significant, long-overdue change in how both providers and patients see medical care.

The study surveyed over 600 physicians by mail, and found that 42 percent believe their patients are getting too much medical care. That’s seven times as many as the six percent who believe their patients aren’t getting enough. Further pressing the case, about 30 percent of PCPs surveyed said that their own practice was more aggressive than they’d like.

Think about what this means. Four years ago, when the Health Policy Program’s director, Shannon Brownlee, published her book Overtreated, most Americans, and a lot of providers, legislators and policy experts thought the only real problem in U.S. healthcare was too little care – because nearly 1 in every 6 Americans was uninsured. Now we have a study that shows that physicians are well aware that overtreatment is also a problem

In one of the great comedy skits of the 20^th century, Geraldine Jones, played by comedian Flip Wilson in drag, delivers chicken to football player Jim Brown. Geraldine holds up the bucket of fried chicken, wiggles her hips and says, “No fancy ribbons on our meat. What you see is what you get!”

In medicine, it’s not so much what you see as who you see that determines what you get. In a new report (by the Health Policy Program’s Shannon Brownlee and Vanessa Hurley, based on analysis by Stanford’s Laurence Baker), the California HealthCare Foundation argues that who you see for your care (and where you live) have a huge effect on the likelihood of receiving a broad variety of elective medical procedures. The variation can’t be explained away by levels of illness in different communities—the study controlled for a number of factors related to illness, including income, level of education, and rates of heart attack and diabetes in the area, as well as typical controls like age, sex, and race. Even after adjusting for all of those factors, the variation didn’t disappear. Areas with the highest usage of angioplasty*, for instance, had rates ten times as high as areas with the lowest use.

Some readers of this blog have heard this before, but it bears repeating: Poor patient understanding of treatment options is a primary cause of such unwarranted variation. When patients don’t have enough information, or information they can understand in order to participate fully in their treatment decisions, the choice of how to manage a condition falls to their doctor.

The 1940 biopic Dr. Ehrlich’s Magic Bullet made famous both the physician who found a treatment for syphilis and the idea there was a single cure for every disease. Most of the old infectious killers have been eradicated, or nearly so, by drugs and vaccines, but the era of the magic bullet is coming to a close. Today’s medical challenges are chronic diseases like diabetes, heart disease, cancer, and Alzheimer’s – diseases that can’t be cured, but only prevented or managed – and we’re trying to address them with a health care delivery system made inefficient in part by the fact that it is caring for chronically ill patients as if they had acute ailments.    

Yet the notion that there’s a single solution to the conundrum of today’s health care delivery system lives on. Proponents of ideas like consumer-driven health care, electronic medical records, the patient centered medical home, comparative effectiveness research, ACOs, and training primary care doctors like to imagine that their preferred solution is the magic bullet, the one technocratic fix that’s going to bring down costs and improve quality.

Maybe it’s time to take a hint from another complex problem: climate change. In a paper published in Science in 2004, climate scientists Robert Socolow and Stephen Pacala argued that rather than waiting around for some new innovation that will magically make all that excess carbon go away, we should be tackling carbon emissions with existing technologies.

Socolow and Pacala called their seven intervention ideas “wedges” because of their shape on the graph (left). Each intervention has a small effect on the level of carbon dioxide emissions, and each effect shows up on the graph as a slice of the stabilization triangle, shaped like a wedge. Put into effect simultaneously, there are enough emissions-reducing technologies–such as carbon capture and storage at power plants and broader use of solar, wind, and nuclear power—to stabilize carbon dioxide levels in the atmosphere for the next 50 years.

In a speech last week at a Health Affairs briefing on “The New Urgency of Cost Control,” Don Berwick, the Administrator of the Center for Medicare and Medicaid Services, applied Socolow and Pacala’s idea to health care costs, arguing that we need to look at a broad range of existing delivery and payment system reforms—each of which is too small to stabilize medical costs individually, but that meet that goal when taken together.

Changes both large and small will be made to the way New York City responds to hurricane emergencies in the future, including how evacuations will be publicized and executed, after officials learned valuable lessons from the unprecedented emptying of the waterfront as Tropical Storm Irene bore down on the five boroughs.

Next time, a neighborhood on Staten Island that was not evacuated may well be. The Housing Authority will make accommodations for pets. The city's Web site will be stripped to the news-you-can-use essentials in emergencies.

Over at NPR’s Planet Money blog, Jacob Goldstein has commented on Columbia professor Barron Lerner's New York Times op-ed about the trouble with unproven, risky cancer treatments. The op-ed calls out heated chemotherapy, an intense treatment for colorectal and ovarian cancer, as dangerous and ineffective. More importantly, he places heated chemotherapy in its place relative to other radical, painful and ineffective treatments like radical and super-radical masectomy, fore- and hindquarter amputation, and very-high-dose chemotherapy. Those treatments all had a moment of popularity, but none was demonstrably more effective than less invasive and dangerous standard treatment options. Rather than actually benefiting the patient, such radical treatments are the illusion of action, serving only to provide false hope while denying patients palliative care that might actually improve their quality of life.

David Clark sat in an ambulance for hours late Saturday night in front of the Park Slope Armory in Brooklyn. Mr. Clark, who is 48 and relies on a wheelchair because of diabetes and a leg injury, was late to receive his medicines. But he still had not even been admitted to the armory, which was a designated shelter for patients with special medical needs who had been displaced because of the storm.

A new study in the Journal the American College of Cardiology finds that doctors at different hospitals vary widely in their assessment of who qualifies as an appropriate candidate for elective coronary angiography (a way to look for clogged coronary arteries).  If Jack Wennberg and his daring band of disruptive Dartmouth Atlas docs have taught us anything, it’s that variation marks the spot for the inconsistent -- and often inappropriate -- use of health care services.

According to researchers at Duke University Medical Center, different hospitals use wildly disparate criteria for determining which patients need non-emergency coronary angiography.  The authors found that hospitals with a lower rate of positive tests -- meaning they test a lot of people who end up not having heart disease -- tend to be more likely to perform angiography on younger, asymptomatic patients. Out of more than half a million medical records examined, the researchers found some hospitals with rates of positive tests as low as 23 percent.

For those who have been following the back and forth over the Less is More blog I posted last week, here's the poster that upset some cardiologists when it was up on the Parsemus Foundation's site.

Over the top? Of course it is -- it's satire! And like all good satire, it contains a few grains of truth mixed with a hefty dose of exaggeration. 

Still, it's only fair to point out that stents aren't really the modern equivalent of leeches. Back when bloodletting was in vogue, it was believed that an excess of blood (one of the four "humors") was to blame for everything from epilepsy to rheumatism to tuberculosis. Got a fever? Let's bleed you! Given the prevailing view of physiology, leeches were an obvious, if entirely wrong-headed, way to rid the body of disease. 

Angioplasty and stents, on the other hand, are backed up by more than belief and theory. In fact, to cardiology's credit, there is a wealth of valid scientific evidence to guide their use. (These two treatments are often called percutaneous coronary intervention, or PCI.) Among the most important studies was the COURAGE trial, published in 2007, which prompted cardiologists to re-examine their assumptions about the effectiveness of PCI, and according to a thoughtful post by Larry Husten (@cardiobrief) at Forbes, has led to a steep decline in their use.