From the 26 February 2016 HealthNewsReview item
Do borders really exist in medicine, where the mere act of crossing political boundaries changes what screening programs are recommended? It seems that they do exist, and they’re well guarded.
Generating numerous headlines in major Canadian papers such as the National Post, The Toronto Star, Globe and Mail and Reuters, the Canadian Task Force on Preventive Health Care came out this week with new recommendations on colon cancer screening, essentially saying that routine colonoscopies were not justified. By contrast, in the United States, the U.S. Preventive Services Task Force (USPSTF) 2015 guidelines say that adults aged 50–75, should have a colonoscopy every 10 years; FIT (fecal immunochemical testing) or gFOBT (guaiac fecal occult blood testing ) annually or flexible sigmoidoscopy every 10 years plus FIT annually.
For this age group the Canadian Task Force says there is insufficient evidence to justify using colonoscopy for routine screening for colorectal cancer. They recommend patients should undergo the fecal occult blood testing every two years or flexible sigmoidoscopy – a procedure which examines the lower part of the colon and rectum every 10 years. These colon cancer screening guidelines, published in the Canadian Medical Association Journal, are for low-risk people: asymptomatic adults, aged 50 to 74 who have no prior history of the disease, no family history or symptoms such as blood in the stool, or a genetic disposition to the disease.
Reminds me of my sister who is a pharmacist. She goes on yearly medical missions to Haiti. The folks working in the pharmacy at the clinic there have only a high school education. My sister is a stickler when it comes to pharmacy practice/licensing in the US. But very much in awe with her Haitian colleagues and what they know and are able to do.
From the 10 March 2016 item at Covering Health:Monitoring the Pulse of Health Care Journalism
A recent news package in The Seattle Times by reporter Will Drabold took a look at how the controversy over dental therapists is unfolding in the state of Washington.
Drabold examined the challenges faced by poor Medicaid patients in seeking dental care. He spoke with health care advocates who believe that technically-trained mid-level providers could bring much-needed care to poor and isolated communities. He also interviewed tribal leader Brian Cladoosby, whose Swinomish tribe had just defied state restrictions to hire a dental therapist. And he spoke with state dental association officials, who made it clear that they – like the American Dental Association – believe dental therapists lack the training to perform these expanded duties.
Dental therapists, who often are compared to nurse practitioners, are trained to deliver a range of services including screenings, cleanings, preventive care, fillings and extractions. While the therapists do work under the supervision of dentists, dental groups often contend that dentists alone have the training to perform what they consider irreversible surgical procedures, such as drilling and extracting teeth.
In spite of resistance from organized dentistry, variations of the therapist model already are being used in Alaska’s tribal lands and in the state of Minnesota. Dental therapists have been approved in Maine and are being considered in a number of other states.
From the 8 March 2015 Rice University news release
HOUSTON – (March 8, 2016) – Approximately 25 percent of Texans say they lack confidence in understanding some of the most basic terminology about health insurance plans, according to a new report released today by Rice University’s Baker Institute for Public Policy and the Episcopal Health Foundation (EHF). The report found uninsured, low-income and Hispanic Texans were least likely to understand health-plan terms like “premium,” “copayment” and “provider network.”
Credit: thinkstockphotos.com/Rice University
The survey asked Texans about their confidence level in understanding seven terms that describe various features of health insurance plans. While one-quarter of all the respondents lacked confidence in their understanding of the terminology, there are significant differences among various subgroups.
Researchers found at least half of those who are uninsured said they didn’t fully understand five of the seven terms. In fact, the rates of lack of confidence for uninsured Texans were nearly double that of those with health insurance.
“This research shows that understanding the key parts of a health insurance plan can be tough, especially for the uninsured,” said Elena Marks, EHF’s president and CEO and a nonresident health policy fellow at the Baker Institute. “These numbers illustrate the continuing need to offer education and outreach targeting the uninsured so they can better understand their health insurance options.”
– See more at: http://news.rice.edu/2016/03/08/new-report-25-percent-of-texans-say-they-dont-understand-basic-health-insurance-terms/#sthash.vadJ9t9y.dpuf
From the 8 March 2016 Texas A & M news release
Imagine that the next time your doctor orders a round of tests, in addition to cholesterol and vitamin D, she also orders a genome sequence. It sounds like science fiction, but the day might come sooner than you think.
Precision medicine—in which each patient’s prevention and treatment decisions are tailored for them—has been a buzzword in the health care industry recently. President Barack Obama launched his Precision Medicine Initiative, and other countries have similar projects underway.
With concerns about the cost of health care, though, can we afford precision medicine?
In certain instances, precision medicine can actually save money. For example, if patients can be screened for drug hypersensitivity before being prescribed certain drugs, they won’t have to be treated later, which is better for patients and cuts down on costs. A similar approach works for choosing treatments.
“When you use a therapy to target only the individuals who will benefit, you avoid wasting drugs or other resources on people who you know won’t get any benefit, and who might actually be harmed,” said David Threadgill, Ph.D., professor and holder of the Tom and Jean McMullin Chair of Genetics at the Texas A&M Health Science Center College of Medicine and director of the Texas A&M Institute for Genome Sciences and Society.
Of course, it’s not quite that simple. “Whether the economics works out in favor of precision medicine depends on two things: the difficulty and the cost of finding the best candidates who will benefit from specific, tailored treatments,” said Robert L. Ohsfeldt, Ph.D., health economist and professor in the Department of Health Policy & Management at the Texas A&M School of Public Health. “You have to know a lot about the disease process and how individual characteristics—genetics and environmental factors like diet or exposure to toxins—mediate the treatment response.”
Continue reading on Vital Record.
From the 8 March 2016 blog item at Selam Selam by Laura Kihlström
Once in a month my husband and I pack Amos in his stroller and walk a few blocks to our closest health care center. We take the elevator to the fourth floor and enter Neuvola, the maternity and child care clinic, or ‘Place for Advice’ as translated freely from the Finnish word.
Neuvola is a Finnish public health care service available for all expectant mothers and children for free.
Maternal and child health is crucial, a cornerstone of development for all countries. Currently in the world approximately 830 women die every day from preventable causes related to pregnancy and childbirth and an estimated 5.9 million children die annually before they reach the age of 5.
The numbers for maternal and child mortality used to be staggering in Finland as well. Just 80 years ago, out of 1000 children a total of 95 died before reaching the age of 5. Now that number is less than 3, one of the lowest in the whole world. Similarly, the rate of maternal deaths used to be high, with 400 mothers dying per 100,000 births. Today, such deaths do basically not occur.
Who are we to thank for this?
The story of Neuvola dates back to the 1920s.
Mr. Arvo Ylppö, a Finnish pediatrician, was determined to decrease infant mortality in Finland. He got his motivation from Germany where he studied and observed, for instance, that the cause of death for prematurely born infants can be traced to treatable conditions instead of simple underdevelopment.
The ideas he then implemented in Finland are, in essence, preventive health care measures.
He supported efforts to educate health care professionals, along with midwives, to municipalities. The services provided by Neuvola were to be free of charge and voluntary. At its core were to be the provision of guidance for mothers and families, a complete vaccination programme as well as the detection of abnormalities in a child’s development as early as possible.
These remain the activities of Neuvola even today.
Neuvola started small, but today it reaches practically all expectant mothers and children in Finland from their birth to the beginning of primary education which is usually at the age of 7. It has been a tremendous success story. My mother used Neuvola services, now I do too. It is a privilege shared by many generations.
It is not an exaggeration to say that Finland is one of the best countries in the world for parents.
From the 8 March 2016 Imperial College London press release
Avoidable harm to patients is still too high in healthcare in the UK and across the globe.
Safety therefore must be a top healthcare priority for providers and policy makers alike.
These are the findings of two reports launched today by researchers from Imperial College London. Both reports, produced by NIHR Imperial Patient Safety Translational Research Centre (PSTRC), provide evidence on the current state of patient safety and how it could be improved the future. They urge healthcare providers to embrace a more open and transparent culture to encourage continuous learning and harm reduction.
The first report focuses on the current system used by NHS staff to report patient safety incidents, called the National Reporting and Learning System (NRLS). The report authors explain this system requires refinement and renovation, so as to take advantage of new technologies and recent behavioural insights. For example app-based technologies offer a simplified platform that engages staff in the incident reporting process. This will not only improve the ease of reporting, but also the accuracy of data reported.
In particular, the report reiterates problems around under-reporting of safety incidents, and reveals structural concerns within the NRLS, that have inhibited its usefulness as a tool to drive safety improvement.
The second report, Patient Safety 2030, suggests a ‘toolbox’ for patient safety. This would include: using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. Other points in the ‘toolbox’ include effective and high-quality education and training; strengthening measurement methods, including incident reporting, and exploring new digital solutions.
However, the authors warn that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and empower patients and staff to become more involved in preventing harm and improving care.
Ultimately, both reports issue a global call-to-action on patient safety: both for individual health systems to convert the evidence on how to improve patient safety into everyday practice, and for the global community of health systems to share learnings from each other’s successes and failures.
The publications: “NRLS Research and Development Final Report”, funded by NHS England, will be presented on March 8th at the Royal Society in London. The “Patient Safety 2030”, funded by a grant from the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK, will be presented on March 9th at the Patient Safety Global Action Summit 2016.
From the 4 March 2014 EurkAlert
AURORA, Colo. (March 4, 2016) – – Researchers at the University of Colorado School of Medicine, along with experts from across the country, have developed a set of policy recommendations that would improve the quality of behavioral health care patients receive in clinical settings.
The Eugene S. Farley, Jr. Health Policy Center, with support from the Robert Wood Johnson Foundation, released recommendations in a report, “Creating a Culture of Whole Health,” that offers practical improvements that would eliminate the artificial separation of “mental health” from “physical health.” The report provides recommendations that call for creating a new approach to health care.
“The health care system differentiates physical and behavioral health care, patients don’t,” said Benjamin Miller, PsyD, director of the Eugene S. Farley, Jr. Health Policy Center and assistant professor of family medicine at the CU School of Medicine. “They seek care in a single setting with providers they trust in clinics that are convenient for them to visit. There should be no ‘wrong door’ preventing patients from accessing appropriate care.”
To improve the quality of care, Miller and the project team make several recommendations. Among them:
- policymakers and payers should establish payment methodologies that support team, not individual, providers;
- policymakers and payers should invest in a national technical assistance center focused on how to improve care by revising federal, state and local policy and regulatory barriers;
- providers should engage communities in service to advancing needs for behavioral health and assure consistency across care delivery;
- providers should share information on how to operationalize successful strategies, such as telehealth; and
- businesses and philanthropies could create resources and technical assistance strategies that improve access to data for patients and other providers.
An excerpt from Quality vs. Quantity by By MICHEL ACCAD, MD at The Health Care Blog (4 March 2016)
“If we bear in mind that medical care consists of decisions and choices made in the face of uncertainty, then the quality of a decision can only be determined in real time, in a specific context, in light of all its alternatives. A third-party payer—public or private, single or multiple—cannot possibly obtain the needed knowledge to make that determination. For an outsider, the quality chasm is metaphysically impossible to cross. Measuring quality is grasping at straws.”
How many times have people said “You must take care of yourself?” when caring for an elderly loved on who’s hospitalized. There’s stress. …too many things to take care…
Source: 13 Tips for Surviving Hospitalization of an Aging Parent or Spouse
Guest post by Vinayak K. Prasad, MD, MPH, and Adam S. Cifu, MD For doctors, it is common to have some doubt about a new medical test, procedure or drug—even one which is widely hailed as remarkable…
For doctors, it is common to have some doubt about a new medical test, procedure or drug—even one which is widely hailed as remarkable or a game changer. It is not cynicism but a healthy skepticism towards marketing over substance. Doctors want to see the evidence that a drug actually works rather than just a good story about why it should work.
Often, however, this skepticism does not last. After a few months, still without any evidence, the doctor finds herself buying in, just a little, to the hype. OK, let me just see what everyone is talking about, she thinks. She begins recommending the drug herself. She still thinks of herself as cautious and conservative—while her colleagues use the treatment widely, she thinks it has a more narrow and defined role. Probably the pill does not work for everyone, but in a select group of people.
A few more years go by, and she gets comfortable with the once-hyped treatment. She now knows how to manage its complications; she thinks she has a good sense of who it benefits; and she considers it a part of her practice.”
Source: Ending medical reversal
What does it take to write an award-winning article? For Richard Mark Kirkner, the process involved finding the right idea, pursuing the reporting doggedly, and then putting it together in one comp…
“In a new How I Did It, Kirkner explains his thinking: “Whenever new medical technology is put to use, hospitals and specialty clinics like to put the best spin on it. But it can take years for such new medical equipment to prove its mettle compared with existing methods.””
Source: Here’s how one journalist discovered the rush to robotic surgery was ahead of the evidence
From the 27 July 2015 Kaiser Health News blog item
A “sleeper” provision when Congress created Medicare in 1965 to cover health care for seniors, Medicaid now provides coverage to nearly 1 in 4 Americans, at an annual cost of more than $500 billion. Today, it is the workhorse of the U.S. health system, covering nearly half of all births, one-third of children and two-thirds of people in nursing homes.
Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.
Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.
Though it provides a vital safety net, Medicaid faces five big challenges to providing good care and control costs into the future:
Large urban hospitals disadvantaged by medicare/medicaid patient satisfaction rating system.
From the 25 May 2015 Mt. Sinai news release
The largest urban health systems do worse on government patient satisfaction scores than smaller, non-urban hospitals according to a new study by Mount Sinai researchers published this month in the Journal of Hospital Medicine.
– May 19, 2015 /Press Release/ ––
The largest urban health systems, which serve as safety nets for large patient populations with lower socioeconomic status and greater likelihood to speak English as a second language, do worse on government patient satisfaction scores than smaller, non-urban hospitals likely to serve white customers with higher education levels, according to a new study by Mount Sinai researchers published this month in the Journal of Hospital Medicine.
Patient satisfaction scores, in part due to the Affordable Care Act of 2010, are a key part of the formula that determines reimbursements levels to hospitals by the Centers for Medicare and Medicaid Services (CMS). The ACA has encouraged hospitals to evolve from a fee-for-service model to one based on measures of value, including patient satisfaction. Hospitals are rewarded or penalized based on metrics that assess quality and efficiency of care in part culled from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.
The study authors suggest that the current formulas need adjustment to be fair to large, urban hospitals, and offer a formula to achieve this equity.
“Our analysis found that the lowest satisfaction scores were obtained from population-dense regions of Washington, DC; New York State, California, Maryland and New Jersey, and the best scores were from Louisiana, South Dakota, Iowa, Maine and Vermont,” said senior author Randall Holcombe, MD, Professor, Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, and Chief Medical Officer for Cancer for The Mount Sinai Health System.
“Across the country, large hospital size and non-English as a primary language predicted poor patient satisfaction scores while white race and higher education level predicted better scores,” said co-author Daniel McFarland, DO, Clinical Fellow, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai. “Other demographic factors were also important but these four were the most significant.”
“This study points out that the interpretation of patient satisfaction scores can be very complex,” said Sandra Myerson, MBA, MS, BNS, RN, Senior Vice President and Chief Patient Experience Officer of the Mount Sinai Health System. “It is important to understand these trends in order to provide the highest quality of patient experience.”
From the 27 July 2015 blog of the Association of Healthcare Journalists
Earlier this month, Thomas Greaney explained the antitrust issuescomprehensively in Health Affairs. “Because each market is local, antitrust analysis would also require an assessment of the competitive overlap in each region,” he wrote. Greaney, is the Chester A. Myers Professor of Law and director of the Center for Health Law Studies at Saint Louis University School of Law.
There is no evidence that insurance or provider monopolies are good for consumers, he wrote, citing Boston and Pittsburgh as evidence that big is not necessarily better in health care or health insurance.
For a good review of the regulatory hurdles insurers face, see this thorough analysisi*** in The New York Times by Robert Cyran. Regulators are concerned about how reduced competition may drive up prices, he explained, writing, “Insurance markets are highly concentrated, and big mergers will make them even more so.”
***Excerpt from The New York Times article
“What’s more, the argument that a big merger would create competition for an even heftier rival has already failed in other industries. In 2011, for example, Sprint, the third-largest cellphone service provider at the time, defended its plan to buy T-Mobile US, the fourth-largest, as necessary to keep its rivals Verizon and AT&T in check. The Federal Communications Commission and the Justice Department rejected the contention, making clear that shrinking the market to fewer than two nationwide carriers would harm consumers.”
So what might persuade the regulators?
The Affordable Care Act could be the answer. President Obama’s health care overhaul creates online exchanges for buying coverage, allowing insurers to expand into new markets without hiring expensive agents. The companies will still need the approval of state commissioners, but the lower barriers to entry should stir more competition – and, at least in the future, appease regulatory fears. It’s unclear whether that would be enough to counterbalance concerns over the top five insurers’ currently chunky market shares.”
Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force (ePub) – Available for download at this site.
Source: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (via USGPO)
The Guide to Clinical Preventive Services presents abridged U.S. Preventive Services Task Force (USPSTF) recommendations on screening, counseling, and preventive medications for use in primary care practice. The 2014 Guide continues the precedent set by earlier editions in providing the Task Force recommendations in a form that provides on-the-job clinical decision support for clinicians. The Guide is organized and cross referenced so that clinicians can search for recommendations alphabetically by topic and by patient category (adult or child/adolescent).
Choosing Wisely is an initiative of the ABIM Foundation that promotes patient-physician conversations about unnecessary medical tests and procedures.
The top five unnecessary tests and treatments have been identified in newborn medicine, according to an article published online July 20 in Pediatrics.
(1) avoiding routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or apnea and desaturation treatment in preterm infants;
(2) for treatment of initially asymptomatic infants without evidence of bacterial infection, routine continuation of antibiotics beyond 48 hours should be avoided;
(3) routine pneumograms for predischarge assessment of ongoing/prolonged apnea of prematurity should be avoided;
(4) in the absence of indication, daily chest radiographs should be avoided for intubated infants; and (5) in preterm infants, routine screening term-equivalent or discharge brain magnetic resonance imaging should be avoided.
“The Choosing Wisely **Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost,” the authors write. “This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.”
Read the entire article here
**Choosing Wisely is an initiative of the ABIM Foundation that promotes patient-physician conversations about unnecessary medical tests and procedures.
From the 7 January 2015 Medical Economics article
The new year brings changes to many evaluation and management codes physicians use, including chronic care management and advanced planning
Read the entire article here
How to save against jaw-dropping prescription drug prices July 17, 2015 by Danielle Braff, Chicago Tribune
From the article
Pharmaceutical experts clued us in on how to get the biggest discounts at the pharmacy counter.
Shop around: A 2013 study by Consumer Reports found that doing a little comparison shopping can have a big payoff, especially if you’re paying out of pocket for your medications. The study found a $749 difference between the highest- and lowest-priced stores when shopping for a month’s supply of five drugs. Costco was the least expensive (and you don’t have to be a member to use its pharmacy), while CVS, Target and Rite Aid were the most expensive.
Be proactive about getting the generic version: Ask if there are generic or less-expensive brand-name drugs that would work just as well as the prescription and over-the-counter medications you’re taking now,” Engle said. “If a generic is not available, check to see if you can use a therapeutic alternative, which is a similar drug that gives the same result that is available as a generic.”
Split pills: Check with your pharmacist to see if your medication is safe to split and — if it is available in a variety of strengths that cost about the same amount.
Read the entire article here
Prescription drug cost assistance (from Health Resources for All Edited by Janice Flahiff)
- Partnership for Prescription Assistance is a directory which helps qualifying patients without prescription drug coverage get the medicines they need for free or nearly free.
- Extra Help (program thru the US Social Security Administration for limited income people)
- NeedyMeds – Non-profit information resource devoted to helping people in need find assistance programs to help them afford their medications and costs related to health care. Includes coverage gap programs.
Patient Engagement: Overused Sound Bite or Transformative Opportunity?
From the 31 March 2015 post at The C Health Blog
Criteria for Stage 3 of meaningful use of EHRs were released recently and there is lots of controversy, as would have been predicted. One set of recommendations that is raising eyebrows is around patient engagement.
The recommendations include three measures of engagement, and providers would have to report on all three of them, but successfully meet thresholds on two.
- Following on the Stage 2 measure of getting patients to view, download, and transmit their personal health data, the Office of the National Coordinator (ONC) has proposed an increase from five to 25 percent.
- The second measure requires that more than 35 percent of all patients seen by the provider or discharged from the hospital receive a secure message using the electronic health record’s (EHR) electronic messaging function or in response to a secure message sent by the patient (or the patient’s authorized representative).
- The third measure calls for more than 15 percent of patients to contribute patient-generated health data or data from a non-clinical setting, to the EHR.
This is all a mouthful, and it’s striking and a bit misguided from two perspectives. First, this requires health care providers to present material to or interact with patients electronically in the name of patient engagement. But it is really mostly about shoveling uninspiring material at our patients that is redolent of highly technical jargon with minimal context, with the belief that it is somehow good for patients to be engaged in this way. The intent is admirable, but the execution flawed. In addition, it is not surprising that many providers have had challenges meeting the Stage 2 requirement that five percent of patients download their medical records. It seems akin to saying that this week’s book club selection is the text for advanced graduate study of quantum mechanics — and then wondering why no one shows up for the meeting.
Some define engagement in terms of how many times consumers or patients interact with informational websites or portals. Both insurers and providers do this. Once again, there is puzzlement over why consumers would choose to spend more time on sites such as BuzzFeed, Facebook and Yahoo, rather than intently study their health benefits or review their lab tests.
At Partners HealthCare Connected Health, our first generation interest in engagement came when we saw, reproducibly, that people who interact with connected health programs have consistently better health outcomes.
This brings up two salient points: The first is how finely we can measure engagement using connected health.
From the 20 July 2015 post at Cardiac Exercise Research Group
…One of the intriguing findings of the study was that measures that could be obtained by a simple verbal interview, without physical examination turned out to be the strongest predictors. Simple metrics such as our self-reported health status and our preferred walking pace was highly predictive in both sexes and across different causes of death. In otherwise healthy people, smoking remained the strongest predictor. Unfortunately, cardiorespiratory fitness measurements were not included in the analysis, but based on our own and others research, we think some simple measure of fitness certainly would be among the most important variables.
From the 2 June 2015 post by Evelyn Cunico, M.A., M.S. at CHIMEconsumerhealth
“Time to Talk Tips” is one of the resources in the “Time to Talk Campaign,” managed by the National Center for Complementary and Integrative Health (NCCIH), at the National Institutes of Health (NIH).
Like any health-related decision, your decision about whether to use complementary health practices is central to your health and safety. Yet, information you find on the Web is not always specific to your illness or based on scientific evidence.
The NIH monthly consumer-friendly series, “Time to Talk Tips,” discusses specific health topics, together with the scientific evidence related to those topics. The series is designed to encourage you and your medical doctors or other healthcare providers to talk about any complementary practice that you are considering.
Examples of “Time to Talk Tips”
Each month, the series highlights a health topic. For example, topics include “Natural Products for the Flu and Colds,” and “What Consumers Need to Know about the Use of Dietary Supplements.”
The series includes simple tips, such as, taking vitamin C regularly does not reduce the likelihood of getting a cold, but may improve some cold symptoms, and some dietary supplements may interact with prescription or over-the-counter medications or other dietary supplements.
Read the entire post here
UCLA scientists explain mechanism that makes their mouthwash so effective against tooth decay | UCLA.
From the 2 June 2015 UCLA news release
Courtesy of Dr. Wenyuan Shi ; S. mutans bacteria, before and after treatment with C16G2.
In 2011, UCLA’s Dr. Wenyuan Shi developed amouthwash that could eliminate the bacteriathat is the principal cause of tooth decay.
A new study led by Shi, chair of the section of oral biology at the UCLA School of Dentistry, describes more precisely the mechanism that makes the mouthwash’s active ingredient so effective.
The research, published in the June issue (PDF) of the Proceedings of the National Academy of Sciences, explains how a specifically targeted antimicrobial peptide, or STAMP, known as C16G2 works to eradicate only the harmful acid-producing Streptococcus mutans bacteria, the main cause of tooth decay, without disturbing the benign and beneficial bacteria in the mouth.
These changes resulted in a microbial community structure that supports better oral health.
The finding is a critical advance because, as scientists have understood for about two decades, the vast majority of bacterial cells in the human mouth are not harmful to our health. Most common broad-spectrum antibiotics and conventional mouthwashes indiscriminately kill both beneficial and harmful pathogenic organisms, and their effects last for only about 12 hours. In addition, overusing broad-spectrum antibiotics can seriously disrupt the body’s ecological balance, which can make people more susceptible to microbial infections. As a result, there is no effective treatment for bacteria-induced tooth decay.
Shi said the STAMP approach would be a unique solution for re-engineering the mouth’s microbiome for long-term health.
C16G2, which is now delivered via a gel tray, is being developed for use in preventing tooth decay and cavities under an investigational new drug application with the U.S. Food and Drug Administration by Los Angeles-based C3 Jian, a company Shi founded around patent rights he developed at UCLA. It is currently in Phase 2 clinical trials.
Single 30-day hospital readmission metric fails to reflect changing risk factors.
From the 3 June 2015 P & T news release
Separate 8-day and 30-day benchmarks would better inform readmission prevention strategies, authors say
A new study from researchers at Beth Israel Deaconess Medical Center suggests that risk factors for readmission change significantly over the course of the 30 days following hospital discharge. Thirty-day hospital readmission rates have become a federal quality metric intended to reflect inpatient quality of care and unnecessary health-care utilization.
Published June 2 in the Annals of Internal Medicine, the research suggests that two distinct 8-day and 30-day readmission rates would serve as better inpatient quality measurements and would better inform readmission prevention strategies.
he authors also noted that other research has shown that hospitals that strictly follow evidence-based care standards do not necessarily have the lowest readmission rates and that readmission rates do not serve as a benchmark for inpatient mortality. Under the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services may reduce payments to acute-care hospitals deemed to have excess readmissions within 30 days of discharge.
The study also found that discharges between 8 a.m. and 12:59 p.m. were associated with lower odds of an early readmission. The authors noted that discharge in the first part of the day likely gave patients and their families more time to access community resources such as pharmacies and social supports, thereby reducing the likelihood of readmission.
The authors also found that social determinants of health are closely tied to readmissions, as they affect how patients access care. They evaluated the effect of barriers to health literacy on readmissions and found that they were associated with both early and late readmissions. A patient’s insurance status was also relevant among those readmitted in the late period; patients with unsupplemented Medicare or Medicaid were more likely to be readmitted 8 or more days after discharge.
“The growing movement toward accountable-care organizations and patient-centered medical homes may prove beneficial in preventing unnecessary hospital readmissions,” Graham said. “Patients discharged from the hospital need support from and teamwork among hospitalists, primary care physicians, nurse practitioners, visiting nurses, pharmacists, and others.”
The authors stressed that both hospital and outpatient settings need systems of care that closely monitor patients as they transition their medical care from the hospital team back to the primary care team. Post-discharge monitoring would better enable a team to make sure patients adhere to the detailed care plan designed by the hospital team, such as taking medications correctly and keeping follow-up appointments.
Source: Beth Israel Deaconess Medical Center; June 2, 2015.
California, Oregon To Allow Hormonal Contraceptives Without A Doctor’s Prescription
From a July 2015 Kaiser Health News post
California and Oregon will be the first states in the nation to allow women to get birth control pills and other hormonal contraceptives directly from their pharmacists – without a doctor’s prescription.
As California officials were busy finalizing regulations on a state law passed in 2013, Oregon’s governor Kate Brown signed a similar bill into law last week.
The two measures were hailed by women’s health advocates. They noted that men have long had an easier time getting birth control, simply purchasing condoms over the counter.
“We support efforts like these that remove barriers to women gaining access to birth control and other reproductive health care,” said Kathy Kneer, President and CEO of Planned Parenthood Affiliates of California, in a written statement.
Read the entire post here
From a May 2015 post at The cHealth blog
We made a decision some years ago to build the case for connected health around the management of these illnesses because:
- They are costly. By some estimates these chronic diseases account for 70% of U.S. health care costs.
- They have a significant lifestyle component. This backdrop seems an ideal canvas for connected health interventions because they involve motivational psychology, self-tracking and engagement with health messages. These chronic illnesses pose a unique challenge in that the lifestyle choices that accelerate them are for the most part pleasurable (another piece of cheese cake? spending Sunday afternoon on the couch watching football, smoking more cigarettes and drinking more beer.) In contrast, the reward for healthy behavior is abstract and distant (a few more minutes of life sometime down the road or an avoided heart attack or stroke). This combination of lack of symptoms and the uphill battle around lifestyle improvement makes these illnesses uniquely challenging.
- They are mostly amenable to tracking some objective bit of information about you (e.g. your blood pressure, blood glucose or activity level) in order to make you more aware and, hopefully improve your lifestyle in order to improve your health.
ocused on these illnesses and the attendant challenges, we developed programs for home blood pressure monitoring, home glucose monitoring and various activity challenges (nothing on cholesterol just yet). By iteration, trial and error, we’ve become comfortable with the psychology around these illnesses and how it affects both our ability to manage patients and the patient’s ability to improve these conditions.
Because these conditions are silent and because most people would rather not be reminded that they have an illness, we found that a strong engagement platform is needed to get people’s attention. We also found that we need to create tools that nudge people to adopt and sustain a healthy lifestyle rather than ignore our natural tendencies to ignore these silent conditions and engage in unhealthy behaviors.
Read the entire blog post here
Despite guidelines, too many medical tests are performed before low-risk procedures.
From the 1 June 2015 EurkAlert
Despite guideline recommendations to limit medical tests before low-risk surgeries, electrocardiograms (ECGs) and chest x-rays are still performed frequently, found a study inCMAJ (Canadian Medical Association Journal).
Evidence indicates that for patients undergoing low-risk surgery, routine testing does not improve outcomes and can actually lead to surgical delays, patient anxiety and other issues. The Choosing Wisely campaign, which started in the United States and spread to Canada and other countries, aims to raise awareness of unnecessary tests and procedures among physicians and patients to decrease their use.
“Rates of preoperative testing before low-risk procedures were higher than expected, given current guidelines and recommendations, with a significant degree of regional and institutional-level variation across hospitals in a large, diverse jurisdiction with a single-payer health system,” writes Dr. Sacha Bhatia, Department of Cardiology and the Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, with coauthors.
There was a 30-fold difference between institutions with the lowest and highest rates of ordering preoperative tests.
Previous studies have looked at patients over age 65, whereas this study included all patients over age 18.
“Our finding emphasizes the need for re-evaluation of ordering decisions and clinical pathways for patients preparing for low-risk procedures. In particular, preoperative anesthesia and medical consultations have been shown to increase preoperative testing rates.”
The authors suggest more research to understand why these tests continue to be performed, which may be useful for institutions in improving their ordering practices.
Active substance targeting dreaded hospital germs.
May 29, 2015 / B3C newswire / — In the German Center for Infection Research (DZIF), scientists from the universities of Tübingen, Münster and Munich join forces and prepare together with the company Hyglos clinical studies on an active substance against the dreaded hospital pathogen Staphylococcus aureus: A highly effective protein from bacteria-specific viruses, so-called bacteriophages, shall rapidly kill the bacteria, which frequently occur in the nose. Due to the specific action, the natural microflora is maintained. Such prophylactic treatment of nasal colonization could counteract the spread of especially methicillin-resistant staphylococcus aureus (MRSA) in hospitals and thereby prevent infections in patients.
Precision medicine is ‘personalized, problematic, and promising’.
From the 10 July 2015 University of Pennsylvania news release
Since President Barack Obama’s State of the Union Address in January 2015, the nation has been talking about a revolution in patient care, known by many as precision medicine.
Of course, the country is used to hearing the president talk about health care, especially the Affordable Care Act. But when the White House starts launching $215 million initiatives to accelerate research—in this case, the Precision Medicine Initiative, according to a White House Press release—you can be sure it’s not just a passing fad.
First, what is precision medicine?
Precision medicine is about tailoring treatments to the patient’s genome and body function. The promise is that this detailed personal health data can determine what’s most effective for each individual, which can lead to better outcomes.
Most of precision medicine’s application currently focuses on cancer. Launched in 2013, Penn Medicine’s Center for Personalized Diagnostics (CPD) helps oncologists determine the best treatment for their cancer patients by looking at the cancer’s genome.
Here’s how precision medicine is being practiced at Penn:
- A patient is diagnosed with cancer.
- If the cancer involves a solid tumor—like breast, lung, or colon cancer—the tumor is surgically removed during a biopsy, and a chunk of the tissue is sent to Penn Medicine’s CPD. If the cancer involves blood or bone marrow—like leukemia—a sample of the blood or bone marrow is sent.
- The CPD sequences a panel of genes that are known to be involved in cancer. This test examines DNA within the tumor, blood or bone marrow sample. The goal is to find DNA mutations that are driving the cancer.
- A report on the mutations found is sent to the patient’s oncologist.
- The oncologist determines if there are therapies or treatments available that work better than others—or not at all—on the patient’s particular type of cancer.
“We’re using precision medicine to give patients the right drugs, guided by the DNA sequence information from their cancer, so we’re not exposing them to potentially toxic effects,” explains David Roth, MD, PhD, director of the CPD. “This individualized therapy is better than treatment based on the ‘average patient.’”
Precision Medicine is being researched, translated and applied across Penn Medicine. Here,
experts from the Center for Personalized Diagnostics share four predictions on how precision medicine will change how cancer is treated in future generations.
1. Cancer will be diagnosed earlier.
Jennifer Morrissette, PhD, clinical director of the CPD:
“There are different stages of tumors. The earlier you catch the tumor, the more likely you are to survive it. My theory is that this century will be the century of diagnostics. We will be diagnosing people’s cancers earlier and earlier.
“That way, we are not dealing with advanced metastatic tumors that have acquired so many different changes that they’re hard to treat. We’ll be capturing tumors very early, in stage one; have a definitive surgery; follow the patient for a certain number of years to make sure that the cancer hasn’t spread; and then they’ll be cured.
“Some people put off seeing a physician because they don’t want chemo, but the longer they put it off, the more likely they are going to have metastatic disease.”
2. Cancer treatment will be based on each person’s health profile.
David Roth, MD, PhD, director of the CPD:
“[In the past,] doctors had been treating [the average patient] based upon results from a large study.
“The revolution in precision medicine is that now we have better tools to understand what’s going on with you as an individual. Instead of saying, ‘Okay, you have this particular cancer, and you have a 30 percent chance. So, go ahead and get this toxic therapy,’ we can be much more specific.
“If we were able to tell you that you have a five percent chance of responding to a chemotherapy based on the makeup of your tumor, would you still do it?”
3. Gene paneling will be used for diagnosis, not just treatment.
David Lieberman, MS, CGC (certified genetic counselor):
“We tend to see certain genes mutated in certain cancers. For example, there is a certain set of
genes [that are] typically mutated in lung cancer or another set in lymphoma.
“It is not always clear using historical methods what type of cancer a patient has. This makes treatment decisions challenging. Sequencing the tumor’s DNA on a panel of known cancer-related genes may help clarify the cancer’s origin and, in this way, assist the clinician in determining treatment or prognosis.”
$215 million: The amount the White House will invest in the Precision Medicine Initiative in 2016
4. More cancer patients will have a treatment team, rather than just an oncologist.
Jennifer Morrissette PhD, clinical director of the CPD:
“It’s not going to be one physician making all the decisions. Cancer treatment has gotten much more complex. Because of the availability of multi-gene testing, you need a group of people with different types of expertise to make the best decision for a patient.
“In addition to the team directing care for the appropriate approach—whether it’s surgery, radiation, chemotherapy, pain management—now there is also the genetic component.
“[The team’s] able to sit in a room with people from the lab who can talk about what the result means, have the oncologist tell them about the patient and then get the clinical geneticist’s notion that there may be an inherited predisposition. Then, they walk out with a consolidated treatment plan for that patient.”
The future of medicine
For more than 250 years, advancements like “precision medicine” have been the hallmark of Penn Medicine. As the first school of medicine in the United States, it has been and continues to be a place where the future of medicine and the future leaders in medicine are being developed.
Public expectations about screening still don’t match what screening programs can deliver.
A guide to weighing up the benefits and harms of health screening programmes
Public expectations about screening don’t match what screening programmes can deliver. By addressing misconceptions about how screening works, its limitations and the calculation of benefits and harms, scientists and clinicians hope to bridge the gap between the active debates of the scientific community and the concerns raised by the public.
Download the guide (PDF) below.
Author: Sense About Science
Document type: Making Sense Of
Published: 3 July 2015
– See more at: http://www.senseaboutscience.org/resources.php/7/making-sense-of-screening#sthash.bv0cknq7.dpuf
Opinion: Will The Joint Commission’s New Standards Keep You Safe from Unnecessary Medical Imaging? | mHealthWatch.
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From the 14 July 2015 mHealth post
The following is a guest contributed post by Karen Holzberger, Vice President and General Manager for Diagnostics at Nuance.
The Joint Commission standards for diagnostic imaging, which recently went into effect, are designed to help prevent duplicate and unnecessary medical imaging of patients, and reduce potentially harmful exposure to radiation when patients need CT scans, MRI or a combination of these and other diagnostic tests. Beginning July 1, 2015, these standards require protocols, documentation and data collection, staff education and other criteria that raise the bar for quality and safety at ambulatory imaging sites, critical access hospitals and accredited hospitals. What do these standards really mean to the patient?
The new imaging standards focus primarily on the radiation dose index. There are a number of uncertainties tied to the long-term impact of imaging on patients, but researchers agree it impact patients differently depending upon sensitivities to radiation, age, body parts being tested, absorption rates and other factors and these are still being studied. In the meantime, to prevent undue risk, The Joint Commission has put a stake in the ground with these specific standards to help improve patient safety. The Joint Commission joins other accredited healthcare organizations, such as the American College of Radiology (ACR) and other clinical associations that are releasing new quality-focused recommendations,enhanced education tools and technologies to make it easier for healthcare teams to keep you safe from unintended risks while you receive diagnostic imaging that could shed light on serious health conditions.
From the 28 May 2015 ScienceLife news release
ancer, all by itself, is bad enough. Although cancer treatment, especially chemotherapy, has become much gentler than it was a decade ago, most interventions still carry significant risks and side effects.
Recently, many physicians have focused on a different sort of hazard that they call “financial toxicity.” Along with the distress of a cancer diagnosis and the discomforts of treatment, patients increasingly have to deal with the cost, anxiety and loss of confidence inspired by large, unpredictable expenses, often compounded by decreased ability to work.
A team led by Jonas de Souza, MD, a head-and-neck cancer specialist at the University of Chicago Medicine, has developed the first patient-oriented website devoted to helping cancer patients understand and cope with financial toxicity (FT). Their goal is to increase awareness of this side effect prior to and during medical treatment so patients know what to expect and can better understand how costs impact them and their families.
Study: 23 pct of US adults with health coverage underinsured.
From the May 2015 Commonwealth Fund study
New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are statistically unchanged from 2010 and 2012, but nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half (51%) of underinsured adults reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost. Among adults who were paying off medical bills, half of underinsured adults and 41 percent of privately insured adults with high deductibles had debt loads of $4,000 or more.
The Affordable Care Act has transformed the health insurance options available to Americans who lack health benefits through a job. Numerous surveys have indicated that the law’s coverage expansions and protections have reduced the number of uninsured adults by as many as 17 million people.1
But Congress intended the Affordable Care Act to do more than expand access to insurance; it intended for the new coverage to allow people to get needed health care at an affordable cost. Accordingly, for marketplace plans, the law includes requirements like an essential health benefit package, cost-sharing subsidies for lower-income families, and out-of-pocket cost limits.2 For people covered by Medicaid, there is little or no cost-sharing in most states.
But most Americans—more than 150 million people—get their health insurance through employers.3 Prior to the Affordable Care Act, employer coverage was generally far more comprehensive than individual market coverage.4 However, premium cost pressures over the past decade have led companies to share increasing amounts of their health costs with workers, particularly in the form of higher deductibles.5
In this issue brief, we use a measure of “underinsurance” from the Commonwealth Fund’s Biennial Health Insurance Survey to examine trends from 2003 to 2014, focusing on how well health insurance protects people from medical costs. Adults in the survey are defined as underinsured if they had health insurance continuously for the proceeding 12 months but still had out-of-pocket costs or deductibles that were high relative to their incomes (see Box #1). The survey was fielded between July and December 2014. This means that we could not separately assess the effects of the Affordable Care Act on underinsurance because people who were insured all year in the survey had insurance that began before the law’s major coverage expansions and reforms went into effect. People who had new marketplace or Medicaid coverage under the Affordable Care Act would not have had that coverage for a full 12 months, as it would have begun in January 2014 at the earliest. Similarly, people with individual market coverage who were insured all year would have spent all or part of the period in plans that did not yet reflect the consumer protections in the law.6
From the 20 May 2015 post at The Health Care Blog
Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.
How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.
What’s the Mechanism?
Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.
That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.
Cost Control Drives Costs Up?
How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.
The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.
If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.
The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.
The Smoking Gun
The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.
The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.
There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.
From the 22 May 2015 post at The Healthcare Blog
I believe the concept of value-based care is good for healthcare. VBC encourages providers to make changes that put the patient at the center of care, so that different services can be provided across providers in a collaborative way. If all went according to the VBC vision, there would be fewer redundant tests, more emphasis on preventative care, and an effort to keep high-risk patients out of the emergency room. It’s also better for costs, something we desperately need in the US, where healthcare spending per capita is more than twice the OECD average.
But Lisa’s story, at the leading edge of the value-based experiment, is not good at all. ACOs and most other value-based models are new, constantly changing, and unproven. ACOs report on 33 metrics that are supposed to represent the quality of care provided by their networks of providers. While still extremely limited in scope, any more than 33 metrics would have made Lisa’s job impossible. So far, few ACOs have reported any savings. Worse — the metrics are unproven. What if they overemphasize standardized process over patient outcomes? And what if efficiency measures result in neglectful and impersonal care? A lot is riding on Lisa’s testing ground.
The administrative challenge
By engaging with and learning from people like Lisa, I have begun to understand the problems frontier administrators face — the same problems countless others will face if we don’t address the administrative burden early on. Here are a few of the top headaches being rolled out in the name of value:
For ACOs, 33 metrics are tracked today. Inevitably, these will expand and change as accountable care evolves. There are also countless other systems of metrics encouraged by other incentive programs: the Physician Quality Reporting System measures, Meaningful Use metrics, Agency for Healthcare Research and Quality Indicators, the Consumer Assessment of Healthcare Providers and Systems for patient experience metrics, indicators for each specialty (Stroke and Stroke Rehabilitation Physician Performance Measurement Set, Endoscopy and Polyp Surveillance Physician Performance Measurement Set, and the Heart Failure Performance Measurement Set, to name a few). The document outlining protocols for the Physician Quality Reporting System is 18 pages long, with a mouthful of a title to match: “The 2015 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures.” Got that? A new piece of legislation that passed the House of Representatives last week — the “doc fix” bill — is about to revamp many of these requirements once again.
Lisa had to fumble through different electronic systems and paper charts to extract the relevant data for each patient in her panel at dozens of different clinics. In many cases, it was clear that care had been provided (e.g. an unstable patient had been upgraded from a cane to a walker), but the documentation wasn’t there (to fulfill the “Screening for Future Fall Risk” metric, documentation must state whether the patient had no falls, one fall without major injury, two or more falls, or any fall with major injury.) Therefore, even though care was provided to prevent future falls, the documentation did not meet the CMS requirement and no credit was given.
For the next reporting year, Lisa is designing her own reporting mechanisms for clinics and doctors. She says that her first reporting experience “was invaluable in learning ways to improve the reporting for year 2015 and beyond,” and she is putting processes in place to facilitate reporting next year. But each clinic is different: some need a page at the front of their paper chart with check boxes, and some have templates in their electronic health records. Her new processes may improve the situation, but additional tracking could also cut into time doctors spend with patients and add to the squeeze they already feel.
Lisa integrated all the data from each clinic manually, and this is a problem for small institutions who are trying to communicate and coordinate with each other. Right now it takes a long time and is not very scalable. Even at larger institutions with leading electronic health record systems, the data is locked away within proprietary databases, often in incompatible formats. Clinical data is rarely integrated with financial and patient-reported data in the way required to tie outcomes and claims to reimbursements in a value-based model.
After all of her data collection, Lisa still had to submit her data to a third part to produce reports, and she will wait many months for the results. The CMS websites are comically complex ; the instruction manual for using the CMS metric reporting interface is 127 pages long.
Putting patients at the center
If these problems aren’t addressed, we’re in for a long and painful healthcare reform. Administrative costs will continue to rise, along with another generation of frustrated physicians and admins. Moreover, value-based care could be deemed a failure not because it’s a bad idea but because of poor implementation. Instead of putting patients at the center of care, it could breed more bureaucracy and force doctors to spend more time reporting on metrics and less time with patients.
We can address these issues and we must — to give value-based care a chance at moving the US toward more patient-centered, less exorbitant healthcare.
From the 22 May 2015 HealthCare Blog post
A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below). In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled. Let’s focus on two consistent distortions.
Evidence-based Medicine (EBM). Few are opposed to evidence-based medicine. What’s the alternative? Ignorance-based medicine? Hunches? However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about 12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients. Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable.
Relative vs. Absolute Drug Efficacy:
Let’s talk a tiny bit about arithmetic. Say we have a medication (called X) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time. Not great, but not atypical of many medications. Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects). But what does the advertisement for drug “Newbe” say? That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie. Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?
Policy: So what does this have to do with healthcare policy? We also want evidence of efficacy with healthcare policies but it turns out that evaluation of these interventions and policies is often harder to do well than are studies of drugs. Interventions and policies are introduced into messy pluralistic systems, with imprecise measures of quality and costs, with sick and not-so-sick patients, with differing resources and populations, with a range of payment systems, and so on and so on. Sometimes, randomized controlled trials are impossible. But sometimes they are possible but difficult to effect. Nevertheless, we argue they are usually worth the effort. Considering the billions or trillions of dollars involved in some policies (e.g., Medicare changes, insurance rules) the cost is comparatively trivial.
But there’s another question: What if a decent research design is used to measure the effects of a large policy in a select population but all you get is a tiny “effect?” What do we know? What should policymakers do? Here’s what we wrote in our recent editorial in the US News and World Report….
From the 19 May 2015 SHEA news release
New research finds that misdiagnoses lead to increased risk of incorrect antibiotic use, threatening patient outcomes and antimicrobial efficacy, while increasing healthcare costs. The study was published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.
“Antibiotic therapies are used for approximately 56 percent of inpatients in U.S. hospitals, but are found to be inappropriate in nearly half of these cases, and many of these failures are connected with inaccurate diagnoses,” said Greg Filice, MD, lead author of the study. “The findings suggest that antimicrobial stewardship programs could be more impactful if they were designed to help providers make accurate initial diagnoses and to know when antibiotics can be safely withheld.”
Additionally, researchers found that overall, only 58 percent of patients received a correct diagnosis, indicating that diagnostic errors were more prevalent in this study than in previous studies unrelated to antimicrobial use. The most common incorrect diagnoses identified by researchers were pneumonia, cystitis, urinary tract infections, kidney infections and urosepsis.
Contributing factors which the researchers said may lead to inaccurate diagnosis and inappropriate antibiotic use include:
- Healthcare workers (HCWs) relying on intuitive processes, instead of analytical processes which are more reliable, safe and effective.
- HCWs experiencing fatigue, sleep deprivation and/or cognitive overload more prevalent in inpatient settings.
- HCWs receiving patients with a previous diagnosis from another provider.
- Lack of clinical experience and minimal personal experience with adverse drug effects.
From a Ponemon Institute web page, May 2015
The Fifth Annual Benchmark Study on Privacy and Security of Healthcare Data by the Ponemon Institute, sponsored by ID Experts, reveals a shift in the root cause of data breaches from accidental to intentional. Criminal attacks are up 125% compared to five years ago replacing lost laptops as the leading threat. The study also found most organizations are unprepared to address new threats and lack adequate resources to protect patient data. Download the study to learn more.
From the 17 May 2015 post by Susan Abram
Patient dumping, or when a hospital discharges a homeless patient to Skid Row or onto the street, has become rare, but still does occur. With so many homeless people who require medical care, hospitals in Los Angeles and across the nation are trying to find ways to help the homeless recuperate after being discharged. There are programs in Los Angeles, but they still are few and far between. Jonathan Lopez, who is a former homeless navigator, has helped many. Many more like him are needed. From my story (Daily News, October, 2013):
From the 28 April 2015 post at Nordic EBM
Evidence-based medicine has been called “cookbook medicine” by some of its more vocal critics. This implies that evil faceless organisations like Cochrane aim to turn all healthcare workers into mindless automatons who blindly follow dictums derived solely from scientific evidence. I hope it doesn’t surprise many in that this has never been the aim of Cochrane, or EBM in general, nor will it ever be. EBM, or EBP if you prefer the term ‘practice’ rather than the more vague ‘medicine’, is a belief system that rests on three pillars (cf. five in Islam). The EBM pillars are: 1) best available scientific evidence (i.e. the purview of Cochrane and yours truly), 2) clinical experience and 3) patient preferences and values. So, the main gist is that evidence doesn’t matter – no matter how scientific – if we don’t have a clinician at hand to interpret it for the benefit of a particular patient equipped with a particular set of values. For example, in a situation where two very similar patients have the same condition, one might wish to achieve speedy return to work whereas the other might rather avoid pain at all cost. The clinician would then use his or her judgment to identify the best course of treatment for both based on experience and what us science types have to offer. However, let us now leave the two pillars of clinical experience and patient preferences to be explored in future posts so that we can chew the first a bit more.
Now, the evidence bit in EBM is often understood to mean results of systematic reviews(a fancy type of research). Inasmuch as they offer an abstracted truth devoid of context (see my earlier post on mathematical ghosts) they still need to be interpreted for use in particular circumstances. This doesn’t always have to be done for every single patient by every single clinician separately. Think of the usefulness of reinventing the wheel for every drive. Often the thinking behind the interpretation and application of evidence can be written down and made use of by many. On a population level this means drafting guidelines. However, it is important to note that when scientific evidence is freely available one does not need to wait for formal committees to grow their beards long enough to formulate official guidelines. Especially when even supposedly professional guideline developers can do a really poor job (see previous post by Margot Joosen). In fact, all informed people and communities should participate in making sense of and advocating for the use of research to back up health decisions. In the end it affects the quality of care they receive.
From the 8 May 2015 post at Science Health
Information about the quality and performance of health care facilities can be confusing to consumers. Dozens of government organizations, trade groups and websites rate doctors, hospitals and long-term care facilities on all kinds of scales, from patient satisfaction to medical outcomes.
In 2008, the Centers for Medicare and Medicaid Services (CMS) attempted to simplify some of this data by creating a five-star rating system for nursing homes. The idea was that public reporting would drive improvement in care, helping nursing home residents and their families choose higher quality facilities, in turn encouraging nursing homes to improve quality to retain residents.
This data can be of limited use, however, for people whose decisions are constrained by insurance networks, cost and geography. People who are enrolled in both Medicare and Medicaid, often called “dual eligibles,” are particularly limited in their choices for long-term care. They are much more likely to have lower incomes, disabilities or cognitive impairment, and to receive low-quality health care in poor neighborhoods than other Medicare beneficiaries.
A new study in the May issue of Health Affairs by public health researchers from the University of Chicago, Harvard, and Penn confirms that despite best intentions, the new rating system exacerbated health disparities between this dual eligible group and non-dual eligible nursing home residents, i.e. those with better financial support. By 2010, two years after the system began, both groups lived in higher quality nursing homes overall, but non-dual eligible residents were more likely to actively choose a higher-rated nursing home. The gap between the two groups also increased: dual eligibles were still more likely to live in a one-star home, and less likely than non-dual eligibles to live in a top-rated home.
From the 14 May 2015 post by the Association of Health Care Journalists
Most medical devices marketed in the United States do not need formal approval from the U.S. Food and Drug Administration.
Members of a panel at Health Journalism 2015 on medical device coverage provided a variety of advice for reporters covering and of the implants, instruments and diagnostic tools common to the modern medical machine.
Moderator of the session was Chad Terhune, aLos Angeles Times reporter who recently found himself chasing an outbreak of carbapenem-resistant enterobacteriaceae (CRE) linked to dirty duodenoscopes. Contributing to the discussion were panelists USA Today investigative reporterPeter Eisler and Scott Lucas, associate director of accident and forensic investigation at the ECRI Institute.
A recent CRE outbreak at Ronald Reagan UCLA Medical Center illustrates the broader issues of medical device approval and oversight. The Olympus scopes used at the Los Angeles hospital, and at other facilities around the nation where the superbug infected patients, did not require any formal study or approval from the FDA before hitting the market because they were considered “substantially equivalent” to a previous models. Equivalency, Eisler explained, allows thousands of devices to move from labs to patients with little more than a short 510K statement that the manufacturer files with the FDA.
Only 10 percent of devices, such as those which “sustain or support life, are implanted, or present potential unreasonable risk of illness or injury” fall into the FDA’s “premarket approval’” category requiring a greater level of regulatory scrutiny, including safety and effectiveness studies, before sale.
Things are not much better once devices hit the market.
It is important to understand that medical devices seldom stand alone, he said. They are usually part of much broader systems used to deliver care safely to patients. When a patient dies after a ventilator fails, for example, it may be that alarms, communications networks or staffing protocols designed to quickly detect and report the failure did not work.
Thus, if reporters want to understand what went wrong in a specific incident, they should ask about more than the device itself. “The system approach to an investigation is key to finding the answer,” Lucas said.
Also be aware that hospitals are supposed to have detailed plans that tell employees what to do when there is a problem with a device. Sequestering machines that malfunction, and downloading data from them before it is purged, are examples of best-practice steps that reporters can ask about.
Handling the pitch
So what should a reporter do when he or she receives a glowing pitch from a local hospital about the latest device?
Terhune suggests starting with Medicare’s open payments database to see if the doctors involved have a financial interest in the device that’s being pitched. While a financial interest is not necessarily a deal breaker for coverage, it is something reporters should know about going in and make sure they can adequately address in their coverage.
Next, look at whatever FDA approval process was required for the device
From the 18 May 2015 post from the Association of Health Care Journalists
When writing about transparency in health care prices and quality, journalists should expose the myths that health care providers promote. That’s the advice Francois de Brantes gave during a session on price and quality transparency at Health Journalism 2015 last month.
Providers promote the false ideas that gathering accurate price and quality data is difficult, if not impossible, and that variations in price result from the severity of illness in populations, de Brantes explained. By debunking these myths, journalists would inform policymakers and the public that there are ways to calculate the prices of medical episodes of care accurately, and that price variation can be controlled. “Price varies because of the way physicians practice,” he said.
Among those myths:
- Price is a trade secret
- Disclosing prices would impede the ability of health plans, hospitals and physicians to compete effectively
- Revealing prices enables collusion and thus violates antitrust law
- Publishing prices leads to higher health care costs.
Both Quincy and Suzanne Delbanco (@SuzanneDelbanco), executive director of the Catalyst for Payment Reform, made the point that price and quality transparency are similar in that both seem simple but are in fact extremely complex topics to cover. Most consumers, for example, are unaware of such quality measures as hospital infection rates and the CAHPS Hospital Survey from the federal Agency for Healthcare Research and Quality, Quincy said.
From the 3 September 2014 post at KevinMD.com
1. Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee-jerk — born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.
2. Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.
3. Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85 year old with congestive heart failure. If I have this test, then what? The answer would have to be: We can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” ten years in the future of someone exceedingly unlikely to live that long.
Press Announcements > FDA launches drug shortages mobile app.
From the 4 March 2015 announcement
Today, the U.S. Food and Drug Administration launched the agency’s first mobile application (app) specifically designed to speed public access to valuable information about drug shortages.
The app identifies current drug shortages, resolved shortages and discontinuations of drug products.
Drugs in short supply can delay or deny needed care for patients. Drug shortages may also lead health care professionals to rely on alternative drug products, which may be less effective or associated with higher risks than the drug in shortage.
“The FDA understands that health care professionals and pharmacists need real-time information about drug shortages to make treatment decisions,” said Valerie Jensen, associate director of the Drug Shortage Staff in the FDA’s Center for Drug Evaluation and Research. “The new mobile app is an innovative tool that will offer easier and faster access to important drug shortage information.”
App users can search or browse by a drug’s generic name or active ingredient, and browse by therapeutic category. The app can also be used to report a suspected drug shortage or supply issue to the FDA.
The agency developed the drug shortages app to improve access to information about drug shortages, as part of the FDA’s efforts outlined in the Strategic Plan for Preventing and Mitigating Drug Shortages.
The app is available for free download via iTunes (for Apple devices) and theGoogle Play store (for Android devices) by searching “FDA Drug Shortages.”
The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.
From the 23 March 2015 MedicalExpress post
Various pills (Photo credit: Wikipedia)
Open the medicine cabinet of a senior and you’re likely to find scores of pill bottles. Physicians are often unaware of all the medications a patient is taking, which can result in unnecessary additional prescriptions, non-prescription medications and potential drug-drug interactions that cause unexpected adverse effects. When a cancer diagnosis is thrown into the mix, the drug-drug interactions can become even more complex. A new study evaluates the currently available screening tools for determining if and when seniors with cancer are taking too many medications and finds that a more comprehensive medication assessment and monitoring plan is needed to improve treatment for this population.
Centers for Medicare and Medicaid Services (Medicaid administrator) logo (Photo credit: Wikipedia)
From the 25 March 2015 Columbia University news release
Quality-Life Year Gains Average $62,000
March 26, 2015 — Researchers atColumbia University’s Mailman School of Public Health analyzed the results of the Oregon Health Experiment, where eligible uninsured individuals were randomly assigned Medicaid or to stay with their current care. Considered controversial because the experiment found no measurable gains for physical health it did reveal benefits for mental health, financial wellbeing, and preventive screening. In terms of quality-adjusted life years, the researchers showed that Medicaid is an excellent value—a $62,000 gain in quality-adjusted life years. Study findings are online in the American Journal of Public Health.
Date:March 26, 2015
Source:H. Lee Moffitt Cancer Center & Research Institute
Summary:The lesbian, gay, bisexual, transgender/transsexual, queer/questioning and intersex (LGBTQI) population has been largely understudied by the medical community. Researchers found that the LGBTQI community experience health disparities due to reduced access to health care and health insurance, coupled with being at an elevated risk for multiple types of cancer when compared to non-LGBTQI populations.
The study highlights that LGBTQI populations face barriers to health insurance such as when partnerships and marriages are not legally recognized; concerns about disclosure in a health care setting, discrimination, misconceptions, legal and financial barriers and the disenfranchised stress and distress of caregiving same-sex partners.
Additionally, there are higher rates of smoking and substance abuse and low screening rates resulting in poor patient outcomes and survival rates for LGBTQI populations. Her review, The Importance of disclosure: Lesbian, gay, bisexual, transgendered, queer/questioning, and intersex individuals and the cancer continuum, was published in the American Cancer Society’s journal, Cancer.
Researchers identified that the real or perceived limited access to care due to fear of discrimination and lack of sensitivity and knowledge of LGBTQI issues stood as roadblocks to patient care. In a study of family physicians only 1 in 80 reported routinely asking patients about sexual orientation, while the majority reported rarely or never asking. The National Institutes of Health and the Institute of Medicine now recognize gender identify and sexual orientation as vital aspects of a health history and the need for improved research in this population.
“For many years, physicians did not ask patients about their sexual orientation. The importance of recognizing gender identity and sexual orientation is critical to ensuring the best quality and evidence-based care is available to patients,” explained Quinn.