Provided by the National Science Foundation
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.
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 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.
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.
[News release] Medicaid Is a Very Good Investment Even If It Does Not Lower Cholesterol, Blood Pressure, or Blood Sugar
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.
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.
Bacteria that cause many hospital-associated infections are ready to quickly share genes that allow them to resist powerful antibiotics. The illustration, based on electron micrographs and created by the Centers for Disease Control and Prevention, shows one of these antibiotic-resistant bacteria. Credit: CDC/James Archer
Antibiotic resistance is poised to spread globally among bacteria frequently implicated in respiratory and urinary infections in hospital settings, according to new research at Washington University School of Medicine in St. Louis.
The study shows that two genes that confer resistance against a particularly strong class of antibiotics can be shared easily among a family of bacteria responsible for a significant portion of hospital-associated infections.
Drug-resistant germs in the same family of bacteria recently infected several patients at two Los Angeles hospitals. The infections have been linked to medical scopes believed to have been contaminated with bacteria that can resist carbapenems, potent antibiotics that are supposed to be used only in gravely ill patients or those infected by resistant bacteria.
“Carbapenems are one of our last resorts for treating bacterial infections, what we use when nothing else works,” said senior author Gautam Dantas, PhD, associate professor of pathology and immunology. “Given what we know now, I don’t think it’s overstating the case to say that for certain types of infections, we may be looking at the start of the post-antibiotic era, a time when most of the antibiotics we rely on to treat bacterial infections are no longer effective.”
The article has more on this “bill”.
‘what if restaurants billed like hospitals?’ Here’s what he came up with.
From the 16 March 2015 Brookings news release
Achieving better health outcomes at a lower cost and succeeding with payment reforms that shift from volume to value is difficult without health information technology (IT). Health IT can engage and support health care providers, patients, and consumers with access to timely and accurate clinical information from electronic health records (EHRs) and other sources. It can also provide access to cost and coverage information that avoids burdensome administrative processes and unexpected costs. Health IT can achieve these benefits through interoperability across information and data exchange platforms – avoiding duplicative parallel systems and additional data entry. Engaged patients and providers, supported by flexible, usable and useful health IT, can make informed shared decisions about testing and treatment which can lead to more timely, efficient, and higher-value health care.
[News release] Insuring undocumented residents could help solve multiple U.S. health care challenges
From the 18 March 2015 UCLA news release
UCLA health care policy analysis finds four key problem areas for Latinos under Affordable Care Act
Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.
Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.
Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:
- The consequences of not covering undocumented residents.
- The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
- The heavier demand on public and private health care systems serving newly insured Latinos.
- The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.
“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”
Insurance for the undocumented
Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.
For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.
For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.
In addition, previous research has shown that undocumented people often delay seeking care for medical problems.
As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.
“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”
From the 10 March 2015 EurekAlert!
Massive health program: $34 billion spent on women and children since 2010; New goal: End preventable deaths of women and young children
An ambitious 2010 initiative to improve the health of women and children around the world has turned into the fastest growing global public health partnership in history, attracting $60 billion in resources. Some $34 billion, nearly 60 percent of the total, has already been disbursed.
The Every Woman Every Child movement has now gathered more than 400 commitments by more than 300 partners around the world, ranging from governments and foundations to business, civil society and low-income countries themselves.
The movement stems from the Global Strategy for Women’s and Children’s Health, launched by United Nations Secretary-General Ban Ki-moon in 2010 to accelerate progress towards the Millennium Development Goals (MDGs) for health.
Every Woman Every Child has set off a major wave in attention to improving essential health care for millions of poor women and children. Major gains in the past five years include greater professional maternity care, family planning, prenatal and postnatal care, childhood vaccinations, oral rehydration therapy and improving access to drugs to prevent mother-to-child transmission of HIV.
The result of such increased care is that maternal and child death rates have fallen in every one of the Global Strategy’s 49-targeted countries in the latest four years.
“The synergy between education and health is evident. Education and health are, quite simply, the drivers of change and development. Education empowers women and girls to live healthier lives and as a result, fewer children are dying. The evidence is clear, better education leads to better health outcomes.
“One of the most important lessons we have learned through the Millennium Development Goals is that to make progress we need an integrated and multifaceted approach,” says Kathy Calvin, president of the UN Foundation. “Effective partnerships are not just about financing; they also tap into partner expertise, innovation, and resources to deliver results. Every Woman Every Child has shown that when each sector contributes its unique strengths and capacities, we can save lives.”
Keys to progress
Significant improvements in key health indicators mainly in 49-targeted countries during its five-year history of Every Women Every Child include:
- 870,000 new health care workers.
- 193 percent increase in prevention of mother-to-child HIV treatment.
- 49 percent increase in oral rehydration therapy for treating infant diarrhea.
- 44 percent increase in exclusive breastfeeding.
- 25 percent rise in post-natal care for women.
- 25 percent rise in skilled birth attendance.
From the 11 March 2015 post by Cindy Nayer at The Health Care Blog
In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?
- CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.
- ACO results have shown ambivalent outcomes.
- Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).
- Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.
As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.
WSB-Atlanta recently explored what happens when hospitals buy physician practices, which has been happening all over the Atlanta area.
Prices for patients go up.
The same physicians – in the same offices, with the same treatments – start charging more.
“Everything is exactly the same,” said cancer patient Mike Rosenberg.
Except the bill.
Sometimes it’s an “outpatient facility fee.” And sometimes it’s a “treatment room fee.”
And it’s a lot of money – sometimes thousands of dollars, not covered by insurance.
And even patients who are savvy enough to know about these fees before they get the bill have a lot of trouble finding out about them, as Erica Byfield made clear in her strong 3-minute report.…
It’s not unique to Atlanta. She quotes a University of California, Berkeley, studythat found that patients generally pay 10 percent more at hospital-owned practices.
The ACA does include incentives for “vertical integration,” or having doctors and physicians part of one organization. But it’s not supposed to raise costs. It’s supposed to bring them down by improving efficiency, creating economies and encouraging care coordination. (Some of the fee problems actually stem from Medicare billing practices, not specifically the ACA.)
How can I order Evidence Reports/Technology Assessments (ERTAs) or Comparative Effectiveness Reviews?
What are Evidence Based Reports?
EPC Evidence-Based Reports (home page and links to reports)
The Agency for Healthcare Research and Quality (AHRQ), through its EPCs, sponsors the development of various reports to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. These reports provide comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies. The EPCs review all relevant scientific literature on a wide spectrum of clinical and health services topics. EPCs also produce technical reports on methodological topics and other types of evidence synthesis-related reports.
Where do Technology Assessments come from?
The Technology Assessment (TA) Program at the Agency for Healthcare Research and Quality (AHRQ) provides technology assessments for the Centers for Medicare & Medicaid Services (CMS). These technology assessments are used by CMS to inform its national coverage decisions for the Medicare program as well as provide information to Medicare carriers.
Fact sheets and reports can be found through The Technology Assessment (TA) Program
How can I order Evidence Reports/Technology Assessments (ERTAs) or Comparative Effectiveness Reviews? [From http://www.ncbi.nlm.nih.gov/books/NBK45610/ (accessed 3 March 2015)]
The Evidence Reports/Technology Assessments (ERTAs) and Comparative Effectiveness Reviews (CERs) are provided to Bookshelf by the Agency for Healthcare Research and Quality (AHRQ). AHRQ has a publications clearinghouse, which can be accessed through this link: http://ahrqpubs.ahrq.gov/OA_HTML/ibeCZzpHome.jsp
United Nations News Centre – Over 5 billion people worldwide lacking access to essential medicines, says UN report
From the 3 March 2015 report
3 March 2015 – Three quarters of the world population has no access to proper pain relief treatment, according to a report by the United Nations body charged with overseeing Governments’ compliance with international drug control treaties, which was released in London today.
Around 5.5 billion people still have limited or no access to medicines containing narcotic drugs such as codeine or morphine the Vienna-based International Narcotics Control Board (INCB) says in its Annual Report for 2014, which went on to point out that around 92 per cent of all morphine used worldwide is consumed by only 17 per cent of the world population, primarily living in the United States, Canada, Western Europe, Australia and New Zealand.
The report, which calls on Governments to address the discrepancy in order to comply with International Drug Control Conventions, notes that natural disasters and armed conflicts around the world can further limit access to essential medicines and the Board stressed that in cases of emergency medical care, simplified control measures can be applied.
For example in the Philippines following the destruction by Typhoon Haiyan in 2013, the Board pointed out to all countries as well as to providers of humanitarian assistance the simplified procedures for the export, transportation and delivery of medicines containing substances under international control.
In its Report, the INCB notes that drug control measures do not exist in a vacuum and that, in their implementation of the drug control conventions, States must also comply with obligations under other treaties, including international humanitarian law and their international human rights obligations, such as allowing civilians to have access to medical care and essential medicines during armed conflicts.
Additionally, the INCB noted that States were charged with deciding specific sanctions for drug-related offences, but should avoid application of the death penalty for such cases.
To achieve a balanced and integrated approach to the drug problem, Governments also should ensure that demand reduction is one of the first priorities of their drug control policies, while they should put greater emphasis on and provide support and appropriate resources to prevention, treatment and rehabilitation, the Report says.
Among the rest of the Report’s findings were an increase in the number of new psychoactive substances (NPS) by 11 per cent and a 66 per cent increase in global consumption of methylphenidate, a stimulant primarily used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD).
The Report also pointed out that the legalization of production, distribution, sale and consumption of cannabis and its derivatives for recreational purposes in Uruguay, together with the moves by States in the United States to legalise sale and distribution of cannabis for non-medical purposes, ran counter to article 4 of the 1961 Single Convention on narcotic drugs, which requires States to limit the use of narcotic drugs to medical and scientific purposes.
[Reblog] How the discussion on dying has changed over 40 years: A conversation with Nancy Berlinger | Association of Health Care Journalists
From the 18 February 2015 post
If you want a refresher on how far society has come on dealing with end-of-life care issues — and what issues are still to be resolved — then this retrospective article in the Feb 12 issue of the New England Journal of Medicine from experts at The Hastings Center is a great place to begin. It reviews the history of the end-of-life care movement in the U.S., takes a look at the integration of palliative care into health care delivery, discusses the still controversial “death with dignity” laws and ethical issues like removal of feeding and hydration tubes.
I recently spoke with co-author Nancy Berlinger, Ph.D., a research scholar at Hastings, about how the conversation on death and dying has changed over four decades.
Q: Why did you and your colleagues develop this retrospective for publication in a medical journal?
NB: It stemmed from a recent revision of The Hastings Center Guidelines [for Decisions on Life-Sustaining Treatment and Care Near the End of Life].
We see lots of ads from hospitals advertising their standards of excellence and their programs. None of them ever advertise their end of life care.
it’s clear that financial incentives are very misaligned with what people need, what they want, what would be medically appropriate. This is a very complex issue – it can’t be undone by a patient, or by an individual doctor or nurse. This has to be the focus of very high-level attention.
Q: What should journalists be focusing on?
NB: Even if they don’t cover the deep medical end of things, they can still ask questions in the context of health and wellness, such as:
- How much power does a sick person have?
- How much power does a really stressed out family have?
- How much power does a doctor, seeing X number of patients, really have?
- And, what still do we want to try to help these people to do? To understand we’re all connected in these efforts.
[Press release] More women now using compounded hormones without understanding the risks — ScienceDaily
From the 28 February 2015 press release
From 28% to 68% of women using hormones at menopause take compounded, so-called “bioidentical” hormones, but women don’t understand the risks of these unapproved, untested treatments, shows an analysis of two large surveys, which was published online in Menopause, the journal of The North American Menopause Society.
Prescriptions of compounded hormones aren’t systematically tracked the way those for FDA-approved drugs are, so the analysts used two large internet surveys of middle-aged and older US women to gauge how commonly they use approved hormone therapy and compounded hormone therapy at menopause. Nearly 3,000 women completed the Harris Interactive Inc and Rose Research LLC surveys, and the researchers used their feedback and US Census data to estimate national use.
They calculated that each year 57 to 75 million prescriptions for all menopausal hormone therapies are filled. Thirty-six million prescriptions are written for FDA-approved hormone therapy, so the remaining 28 to 39 million prescriptions are likely for compounded hormones.
But it seems that women who take them don’t know what they’re getting into. One survey asked women “Do you believe that bioidentical hormone therapies compounded at a specialty pharmacy are FDA-approved?” Only 14% correctly answered “no.” Most–76%–weren’t sure, and 10% incorrectly answered “yes
From the 17 February 2015 post
That’s right…it really happened.
At the conclusion of a recent doctor visit, he gave me his cell phone number saying, “Call me anytime if you need anything or have questions.”
In disbelief, I wondered if this was a generational thing – and whether physicians in their late thirties had now ‘gone digital’.
My only other data point was our family pediatrician, who is also in her late thirties. Our experience with her dates back nearly seven years when my wife and I were expecting twins. A few pediatricians we met with mentioned their willingness to correspond with patients’ families via email as a convenience to parents. The pediatrician we ultimately selected wasn’t connected with patients outside of the office at that time, but now will exchange emails.
From the 26 February 2015 article at Covering Health
Health insurers are taking incremental steps to release information on what they pay to health care providers. Each month, they reveal just a bit more.
This week, Aetna, Assurant Health, Humana and UnitedHealthcare released state and local cost information through the nonprofit Health Care Cost Institute (HCCI) on a consumer site called Guroo.com. The data show the costs for about 70 common health conditions and services and are based on claims from more than 40 million insured individuals, HCCI announced.
No other organization has made these data available, HCCI said. In that way, this release is significant. Or, as the Guroo site says of the data: “The biggest collection of cost information is now at your fingertips, so you know what care really costs.”
Well, not exactly. The data show what insurers paid. Or, as Jason Millman pointed out in The Washington Post, “The site doesn’t break down what a consumer pays for services versus what the insurer pays.”
The release of cost-transparency data seems to be gaining some momentum. Last month, the North Carolina Department of Health and Human Services published what it said was “the most current price information” from hospitals and ambulatory surgery centers. In so doing, North Carolina joined Maine and Massachusetts as the only states that publish price data on the web, according to last year’s Report Card on State Transparency Laws from the Catalyst for Payment Reform and the Health Care Incentives Improvement Institute.
Within days of the publication of the state data, Blue Cross Blue Shield of North Carolina published data on what it pays hospitals and physicians. In an earlier blog post we covered those events in North Carolina.
One person’s journey through an unhealthy health care system. Definitely not patient centered. Have had similar insurance problems, mostly because of errors in the insurance company erring in my personal identifiers.
Let me start this story by telling you the end: I am just fine. For those of you who like me, there is nothing to worry about and all is well. For those of you who don’t like me, sorry to disappoint you, but you’re stuck with me for a while.
I’m telling you these things—news to make you happy or disappointed, depending on your point of view about me—because this story is about my recent trip to the hospital, an unexpected journey that I wasn’t sure I was going to talk about publicly.
And from one of the comments…
You sound true and authentic to me too. I am embarrassed as to how often we do screw up. The only excuse I think is that we have so much internal and external regulation that we become nervous nellies, unable to relax and enjoy what we are doing. You should go to a Pharmacy and Therapeutics meeting in a hospital and listen to the barrage of complaints from everyone to everyone. Wrong dose, wrong timing, wrong drug, wrong patient. I have walked out of these meetings because of the hostility. We would all do better if we could start some little village clinic in the Congo, without the interminable watching from a thousand eyes.
From the 21 February 2015 item by Teagan Kuruna (the MPH formerly known as Teagan Keating)
…While at Boston City Hospital, [Dr.] Rich saw a steady stream of young Black men come through the emergency room with stabbing and gunshot wounds. He also began to realize that everyone, including the other medical staff, saw these men as perpetrators rather than victims. The general consensus was that these men had done something to get themselves injured instead of what was obvious to Rich: these young Black men were truly victims.
Because of his compassionate streak, Rich began interviewing these men to learn more about their lives and what led to them returning to the ER over and over. He learned that the injuries that brought them to him were often due events outside their control–a robbery, a few wrong words to the wrong person, a simple accident that escalated to violence. After talking with them as they received treatment, Rich realized that the men were suffering from post-traumatic stress syndrome. Even worse, their injuries were stitched up and they were sent right back out to the same environment that brought them to the ER.
Rich wrote a book about these experiences called Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men.
From the 20 February 2015 post by Joseph Burns at Covering Health (Association of Health Care Journalist)
At a conference last year, Michael Laposata, M.D., Ph.D., one of the nation’s best known pathologists, explained how clinical laboratories could deliver more value to patients, physicians, and health insurers. To do so, pathologists and laboratory scientists need to provide more detailed explanations about lab test results because even physicians who order genetic and molecular tests are often confused about the results, said Laposata, chairman of the Department of Pathology at the University of Texas Medical Branch.
When he explains test results to ordering physicians, he frequently refers to an “allele” which is one of two or more versions of a gene, he said. When he does, physicians sometimes ask, “What’s an allele?”
His anecdote is telling following President Obama’s announcement last month that he recommended spending $215 million on the precision medicine initiative. The announcement was correctly hailed as an important and needed investment in medical technology. “Precision medicine” is described by the National Institutes of Health as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.”
Given that there is and will continue to be a lot of hype about precision and personalized medicine, we may want to check our expectations, because the hurdles are daunting, as Tabitha M. Powledge wrote for the Genetic Literacy Project. “The plan embodies a wonderfully human let’s-climb-Everest-because-it’s-there aspiration. But you also have to wonder about the practicality of such a sweeping program,” she explained.
There is not much good, proven, scientific, medical uses for what we’re talking about as personalized or precision medicine,” Greely said. “And yet, we … sell and we hype as if there is much more.”
“Here’s the problem: because personalized medicine is in the realm of OMG-that’s-too-complicated science, the usual watchdogs don’t see it. Plus the big academic medical centers love the grants that it generates.”
Even health insurers are struggling to understand the full implications of genetic and molecular testing…
“…. many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning.”
Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input.
In other words, just because it’s a “health” app doesn’t mean its necessarily so.
Among other issues, this is definitely a mental health concern. As quoted above, Serious mental illness affects men and women in jail at rates four to six times higher in the general population.
Bill Branson (Photographer)
A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?
How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.
Those economics of a “negative price” trump Dr. Emanuel’s advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America’s PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.
Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are “not associated with lower rates of mortality” but “may be associated with more diagnoses and more drug treatment.”
The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision — and even to attach money (incentives and penalties) to checkups — if they are willing to summarize the above-cited clinical findings for their employees.
If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.
Excerpt (longish post)
But, there are many things that data will never do well. For certain things, physician heuristics may lead to better decisions than any predictive model.
Heuristics are shortcuts, based on experience and training that allow doctors to solve problems quickly. They are pattern maps that physicians are trained to recognize. But, heuristics have a reputation for leading to imperfect answers: Wikipedia notes that heuristics lead to solutions that “(are) not guaranteed to be optimal, but good enough for a given set of goals…. (they) ease the cognitive load of making a decision.” Humans use them because we simply can’t process information in sequential binary fashion the way computers do.
It would be a mistake to call heuristics a sad substitute for big data. Some cognitive scientists have made the argument, and I think they’re right, that heuristics aren’t simply a shortcut for coming to good-enough answers. For the right kinds of problems, heuristically generated answers are often better than the those generated by computers.
How can this be?
I often think of the following cartoon in Randall Munroe’s superb recent book, What If? Serious Scientific Answers to Absurd Hypothetical Questions. In trying to compare human and computer thinking, he rightly notes that each excels at different things. In this cartoon, for example, humans can quickly determine what they thought happened. Most people can tell you that the kid knocked over the vase and the cat is checking it out, without going through millions of alternate scenarios. Monroe notes that most computers would struggle to quickly come to the same conclusion.
So, from the perspective of an emergency doctor, here are the three leading problems with the applied use of complex analytics in the clinical setting:
- 1. The garbage in, garbage out problem. In short, humans regularly obfuscate their medical stories and misattribute causality. You need humans to guide the patient narrative and ignore red herrings.
- 2. If we want to be able to diagnose, screen and manage an ER full of runny-nosed kids with fevers, we simply can’t afford the time it takes for computers to sequentially process millions of data points. The challenge is at one simple and nuanced: allowing 99% of uncomplicated colds to go home while catching the one case of meningitis. It’s not something that a computer does well: it’s a question of balancing sensitivity (finding all true cases of meningitis among a sea of colds) and specificity (excluding meningitis correctly) and doctors seem to do better than computers when hundreds of cases need to be seen a day.
- 3. There is a problem with excess information, where too much data actually opacifies the answer you’re looking for. Statisticians call this “overfitting” the data. What they mean is that as you add more and more data points to an equation or regression model, the variability of random error around each point gets factored in as well, creating “noise”. The more variables, the more noise.
The paradox is that ignoring information often leads to simpler and ultimately better decisions.
Some bandages are embedded with medicine to treat wounds, but researchers at Harvard University and Brigham and Women’s Hospital have something much more sophisticated in mind for the future of chronic wound care. With support from the National Science Foundation, engineer Ali Khademhosseini and a multidisciplinary team are bringing together advances in sensors, biomaterials, tissue engineering, microsystems technology and microelectronics to create “smart bandages” for wounds that require ongoing care, such as burns, diabetic ulcers and bed sores. The new devices, known collectively as flexible bioelectronics, will do much more than deliver medicine. They will be able to monitor all the vital signs of the healing process, such as oxygen levels and temperature, and make adjustments when needed, as well as communicate the information to health professionals who are off-site. To fulfill the critical need for flexibility, the team is testing new materials, such as a hydrogel that would cover a wound with just the right amount of stretch to be comfortable.
Provided by the National Science Foundation
On a related note, during Peace Corps training in Nashville (1979) I came down with a bad cough, often coughing for 5-10 minutes at a time. Don’t think the rainy weather and me going around with an umbrella or raincoat helped. Anyways, was sent to an area doctor and after a few tests, told me and the Peace Corps staff not to be concerned. Just a dormant fungus (and I do live a bit north of the Ohio River Valley). Anyways, after a few days in Monrovia, Liberia (6 am temps of about 85), I stopped coughing.
PS We were boarded in motels. One late night was awakened by a few young men in the group coughing loudly and giggling outside my window. Chalk it up now to some late night drinking and the men still being, well, young.
On another note, my husband quit smoking back in the 80’s after about 25 years of smoking. He had a lung X-ray and a dark spot on the lungs was noticed. He had quit smoking the month before. So now I’m wondering…cancer or fungus? He has not had any firm diagnosis of cancer since.
Beschreibung: Konventionelles Röntgenbild des Thorax (der Lunge) mit rundlicher Verdichtung in der linken Lunge Quelle: selbst erstellt –Benutzer:Lange123 17:18, 11. Nov. 2004 (CEST) (Photo credit: Wikipedia)
From the 9 February 2015 article By MATT HAWKINS, MD at The Health Care Blog
…Histoplasma capsulatum is a fungus endemic to the Ohio and Mississippi River Valleys. It is everywhere. You get it by breathing. Prior studies suggest that >80% of those living in these regions have contracted the fungus. The majority of people with histo don’t get sick. But – they get lung nodules. Lots of them. The nodules are benign but often indistinguishable on imaging from “early” lung cancer.
The entrepreneurial owners of the pictured urgent care center likely know this. They also know that Medicare and other carriers have limited coverage (reasonably so) to patients between the ages of 55 and 74 with at least a 30 pack year history of smoking. If patients have quit smoking, they must have quit within 15 years to be eligible for coverage. At first glance, it may seem like offering cheap, $88 screening for Americans ineligible for lung cancer screening coverage, or those eligible citizens too busy to get a physician order for a screening exam, is a good deed. But, $88 is just the tip of the iceberg. Additional screening exams and subsequent procedures/biopsies will all incur additional costs.
Our collective fear of malignancy, the unfortunately high frequency of lung cancer, and the promise of low dose CT screening for this disease will drive people outside of the NLST’s strict inclusion criteria into these low-cost, high-volume CT-scanning conveyor belts to “catch the cancer early.”
And what will they find in the Ohio River Valley?
Lots and lots of lung nodules.
The markedly increased propensity of patients in this region to have pulmonary nodules is likely to lead to an increased number of image-guided and open surgical biopsies (when the image-guided biopsy provides insufficient tissue for analysis). More invasive procedures will naturally lead to more cost-inducing complications (such as pneumothorax and pulmonary hemorrhage) and, in some instances, death.
For Immediate Release
February 6, 2015
Contact: Todd Kluss
A new report from The Gerontological Society of America’s Workgroup on Cognitive Impairment Detection and Earlier Diagnosis outlines a course of action for increasing the use of evidence-based cognitive assessment tools as part of the Medicare Annual Wellness Visit (AWV).
The AWV was established by 2010’s Affordable Care Act to allow Medicare beneficiaries to receive preventive and assessment services during visits with their primary care providers. And although detection of cognitive impairment is among the required AWV services, no specific tools are mandated and no data are available regarding tools used for this purpose.
The new report outlines a plan for addressing this shortcoming and shows how increased detection leads to earlier and optimal diagnostic evaluation, referral to post-diagnosis support and educational services in the community, and ultimately to improved health-related outcomes and well-being for Medicare beneficiaries with diagnosed dementia and their families.
“The Medicare AWV offers a universal opportunity for primary care providers to start a conversation with older adults and their families about cognitive changes that might be worthy of further investigation,” said Richard Fortinsky, PhD, chair of the workgroup. “Our workgroup’s report provides guidance for providers so they can start this conversation and, as appropriate, employ evidence-based assessment tools to detect cognitive impairment.”
The report is available at www.geron.org/ci. The website also contains a link to a companion webinar held in January, led by workgroup members Katie Maslow, MSW, and Shari M. Ling, MD.
“Increased detection of cognitive impairment is essential for earlier diagnosis of Alzheimer’s disease and related dementia — and also earlier diagnosis leads to more timely linkage of older adults and their families with community-based services and supports,” Maslow said.
In the report, the workgroup outlines a recommended for four-step process achieving its goals.
Step 1 is to kickstart the cognition conversation. To increase detection of cognitive impairment and promote earlier diagnosis of dementia in the Medicare population, the GSA workgroup endorses that primary care providers use the AWV as an annual opportunity to kickstart — that is, to initiate and continue — a conversation with beneficiaries and their families about memory-related signs and symptoms that might develop in older adulthood.
Step 2 is to assess the patient if he or she is symptomatic. The GSA workgroup endorses use of a cognitive impairment detection tool from a menu of tools having the following properties: it can be administered in
five minutes or less; it is widely available free of charge; it is designed to assess age-related cognitive impairment; it assesses at least memory and one other cognitive domain; it is validated in primary care or community-based samples in the U.S.; it is easily administered by medical staff members who are not physicians; and it is relatively free from educational, language, and/or cultural bias. The report provides a list of tools that may be suitable for this purpose.
Step 3 is to evaluate with full diagnostic workup if cognitive impairment is detected. The GSA workgroup recommends that all Medicare beneficiaries who exceed threshold scores for cognitive impairment based on the cognitive assessment tools used in step 2 undergo a full diagnostic evaluation. Numerous published clinical practice guidelines are available to primary care providers and specialists to help them arrive at a differential diagnosis.
Step 4 involves referral to community resources and clinical trials, depending on the diagnosis. The GSA workgroup recommends that all Medicare beneficiaries who are determined to have a diagnosis of Alzheimer’s disease or related dementia be referred to all appropriate and available community services to learn more about the disease process and how to prepare for the future with a dementia diagnosis.
“The GSA workgroup views this suggested four-step process as a framework for communicating with a wide variety of stakeholders about the critical importance of incorporating cognitive impairment detection into everyday clinical practice with older adults,” Fortinsky said. “We look forward to building on this report by helping to plan additional activities intended to disseminate and implement the report’s recommendations in communities throughout the country.”
The Gerontological Society of America (GSA), the nation’s oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, theAssociation for Gerontology in Higher Education.
Technology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.
In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.
This humorous equation speaks volumes about technology and health care:
NT + OO = COO
New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.
For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?
Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?
Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?
When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.
The intersection between rising consumerism and a growing retail orientation in the health care sector presents challenges, some unprecedented, for existing players. We explore three shifts that health industry players should respond to, and that can set the scene for greater consumer involvement.
Matching a buyer with a seller. On Angie’s List it’s simple: Consumers search, select, and schedule the services that fit their needs.
Could it ever be that easy in health care?
The cost of health care is high and rising. For the past 10 years, health care costs have exceeded US economic growth by an average 2.5 percent annually. The anticipated average annual growth rate of health care costs is 5.7 percent per year through 2023, well above gross domestic product (GDP), average wages, and productivity gains.1 Improving economic conditions, the impact of the ACA’s insurance coverage expansions, and an aging population are expected to drive health care expenditure growth.2 Average annual growth of out-of-pocket health care expenditure is projected to rise to 5.5 percent by 2023 from 3.2 percent in 2013.3
The health care system in the United States is edging toward a recalibration. Existing business models are being challenged to find and deliver new sources of value and to develop innovative approaches to make health care less complicated, and to improve outcomes:
Health care is moving toward value, not volume, as a central organizing principle. That impacts how patients are cared for, how physicians and hospitals are paid, and how life sciences companies approach the market.
Those paying the bills—employers, government, health plans, and increasingly, individuals—are looking for better value and better outcomes.
Entrepreneurs, retail organizations, and communications and technology companies see opportunity in the large and growing health care market. Taking advantage of developing trends, they are slipping across the industry’s increasingly permeable boundaries.
Independent journalist Lola Butcher reports that debate about the government’s 340B Drug Pricing Program continues to build as the program expands.
“Like all good controversies, this one has enthusiastic advocates and wild-eyed opponents, and it’s easy to get snagged by the passion of the partisans,” she writes in a new tip sheet.
The program, which started in 1992, requires pharmaceutical companies to sell outpatient drugs to eligible health care organizations at significantly reduced prices.
Over the years, the eligibility criteria to participate has expanded repeatedly. Currently, safety-net hospitals, children’s hospitals, critical access hospitals, federal health centers and other organizations are eligible; organizations that fall into those categories must register and enroll in the 340B program.
Butcher, as a 2014 AHCJ Reporting Fellow on Health Care Performance, wrote about the migration of cancer care from physician-owned clinics and community centers to hospital outpatient departments. She found that the 340B program helped fuel that trend.
In this tip sheet for reporters, she explains the program, including the program’s winners and losers, how much money is involved and story ideas.
From the 4 February 2015 Mayo Clinic press release
PHOENIX – While surgical outcomes have improved nationally over time, surgical outcome reporting does not necessarily lead to better outcomes, according to a Mayo Clinic study published this week in the Journal of the American Medical Association.
Systems that capture, analyze, and report surgical outcomes are an increasingly important part of the quality improvement movement in health care in the United States. Within the U.S., the most widely used surgical outcomes reporting system is the National Surgical Quality Improvement Program (NSQIP), which is coordinated through the American College of Surgeons.
The study analyzed data regarding surgical outcomes — complications, serious complications, and mortality — in over 345,000 patients treated between 2009 and 2013 at academic hospitals throughout the United States. Of these patients, approximately half were treated at hospitals that participated in the NSQIP. The study showed that surgical outcomes significantly improved overall in both study groups during the period of analysis.
“In our study we weren’t interested in whether patients had better outcomes in NSQIP vs. non-NSQIP hospitals,” says David Etzioni, M.D., chair of Colorectal Surgery at Mayo Clinic in Arizona and the study author. “We wanted to know whether the outcomes experienced by patients treated at NSQIP hospitals improved, over time, in a way that was different from patients treated at non-NSQIP hospitals.”
The study found no association between hospital-based participation in the NSQIP and improvements in postoperative outcomes over time, suggesting that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement. According to the research team, the failure of these types of outcomes monitoring systems to produce measurable improvements in outcomes may be related to difficulties in identifying mechanisms that translate reports into changes in how surgical care is provided.
“I think if there is one lesson that we have learned at Mayo Clinic; real quality is achieved through a system — not just a doctor, not just a nurse or other staff,” Dr. Etzioni says. “All of these elements of care have to work together closely to provide patients with the best possible outcomes.”
From the 3 February 2015 press release
An examination of process measures endorsed by the National Quality Forum finds that these measures focus predominantly on management of patients with established diagnoses, and that quality measures for patient presenting symptoms often do not reflect the most common reasons patients seek care, according to a study in the February 3 issue of JAMA.
Health care reform efforts, such as accountable care organizations, focus on improving value partly through controlling use of services, including diagnostic tests. Publicly reported quality measures that evaluate care provided prior to arriving at a diagnosis could prevent financial incentives from producing harm. The National Quality Forum (NQF) currently serves as the consensus-based quality-measure-endorsement entity called for in the Affordable Care Act. Endorsed measures are often adopted by the Centers for Medicare & Medicaid Services in payment and public reporting programs, according to background information in the article.
Hemal K. Kanzaria, M.D., M.S.H.P.M., of the University of California, Los Angeles, and colleagues examined NQF-endorsed process measures that evaluate the prediagnostic (prior to making a diagnosis) care of patients presenting with signs or symptoms. There were 372 process quality measures listed on the NQF website as of June 4, 2014; from these, 385 codings were determined, by categorizing the process quality measures by a system developed by the Institute of Medicine. Approximately two-thirds (n = 267) targeted disease management and 12 percent (n = 46) targeted evaluation/diagnosis. The remaining were evenly distributed among prevention, screening, and follow-up.
Of 313 measures pertaining to evaluation/diagnosis or management, 211 (67 percent) began with an established diagnosis, whereas 14 (4.5 percent) started with a sign/symptom. The sign/symptom-based measures focused on geriatric care (e.g., memory loss, falls, urine leakage) or emergency department care (e.g., chest pain). In contrast, many common reasons for which patients seek care, including fever, cough, headache, shortness of breath, earache, rash, and throat symptoms, were not reflected by the quality measures. The performance of a lab test or medical imaging study was the action required by 59 of 313 (19 percent) endorsed quality measures; many others required actions related to medication prescribing.
Recent research indicates that most of the variation in hospital readmission rates in the United States is related to geography and other factors over which hospitals have little or no control. Access and quality of care outside of the hospital setting seem to be especially important.
A new editorial that addresses these findings notes that a broader focus on community health systems, not just performance of individual hospitals, may be needed to reduce hospital readmissions.
Because high readmission rates trigger reductions in Medicare reimbursements to hospitals, facilities in socioeconomically disadvantaged and underserved communities may be disproportionately penalized. The editorial is published in Health Services Research.
Access and quality outside the hospital may affect the degree to which the HRRP can achieve its intended outcome, fewer readmissions, but other factors are likely to determine whether the policy is an operational success. For the HRRP, operational success could be defined as whether hospitals respond in a manner consistent with the underlying motivations of improving quality of care and reducing costs. In terms of improving quality, a recent meta-analysis of randomized trials found that interventions designed to prevent readmissions tended be moderately effective (relative risk of 30-day readmission 0.82, 95 percent CI, 0.73–0.91). The studied interventions addressed care both during and after hospitalization, such as through case management, patient education, home visits, and patient self-management support, among other activities. Multifaceted interventions were more common and were 30–40 percent more effective than one-dimensional ones (Leppin et al. 2014), yet they may also be more challenging to implement and more costly. The degree to which hospitals nationwide are implementing quality improvement interventions that target readmissions does not appear to have been described.
A study including data from 346 hospitals found that readmissions during the first 30 days after surgery were associated with new complications—post-discharge problems related to the surgical procedure—and not, as previously suspected, to the worsening of medical conditions the patient already had or acquired while hospitalized for surgery.
In this study, published in the February 3 issue of JAMA, Ryan P. Merkow, MD, MS, a clinical scholar in residence at the American College of Surgeons, now chief surgery resident at the University of Chicago, and colleagues examined the reasons, timing, and factors associated with unplanned postoperative hospital readmissions within 30 days after surgery.
Financial penalties for readmissions have made them an important quality and cost-containment issue for hospitals and clinicians. Hospitals try to reduce readmissions, but until now little has been known about the reasons for readmission after surgery. Identifying these reasons could advance quality-improvement efforts and reduce surgical readmissions.
“The Hospital Readmission Reduction Program is federal law and is here to stay,” Merkow said. “Hospital administrators and quality departments must determine how to approach readmissions, and in particular readmissions after surgery.”
“Until recently, efforts were primary focused on medical conditions,” he said, “namely heart failure, myocardial infarction and pneumonia. However, a growing emphasis by policy makers now specifically targets readmissions after surgery. Yet, surprisingly, little is known about why surgical patients are being readmitted. It is completely unclear if oversight initiatives such as public reporting and pay-for-performance should be similarly applied to both medical and surgical patients.”
“Unlike patients being admitted for a medical condition, surgical patients experience a discrete, invasive event (i.e., surgery) with known risks of complications,” Merkow said. “We believe this study definitively separates medical and surgical readmissions as distinct entities that require unique reduction strategies.”
In this study, the unplanned 30-day readmission rate following 498,875 operations was 5.7 percent. Rates ranged from 3.8 percent after hysterectomy to 14.9 percent after lower-extremity vascular bypass. Only 2.3 percent of patients were readmitted for a complication they had experienced during their index hospitalization.
The researchers found that the most common reason for unplanned readmissions was surgical-site infections, followed by intestinal ileus or obstruction, bleeding or anemia, blood clots, and surgical-device issues. Surgical-site infections (SSI) ranged from 11.4 percent after bariatric surgery to 36.4 percent after lower extremity vascular bypass.
The findings have at least two significant policy implications, the authors insist. First, because most readmissions result from post-operative complications, “readmissions after surgery penalize hospitals twice.” And second, because it has been difficult to reduce the most common post-operative complications, such as surgical site infections, penalizing hospitals for problems they do not know how to prevent could be counterproductive, leading to untested solutions that may be ineffective or even counterproductive.
“Understanding the underlying reasons for readmission, the timing, and the associated factors should help hospitals undertake targeted quality-improvement initiatives to reduce readmissions,” the authors wrote. “However, surgical readmissions mostly reflect post-discharge complications, and readmission rates may be difficult to reduce until effective strategies are put forth to reduce common complications such as SSI.”
Efforts should focus on reducing complication rates overall rather than just those that occur after discharge, the authors insist. “This will subsequently reduce readmission rates as well. Readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather better suited as a measure for hospitals to track internally.”
The research showed that both:
- one-to-one talking with a specific nurse
- using a stress ball
both significantly reduced the pain and anxiety of the varicose vein surgery.Interesting, watching a DVD during the surgery reduced the anxiety, but not the pain of varicose vein surgery. Listening to music had no effect.
This study is part of the continuing research program that makes treatment at The Whiteley Clinic unique.This projectwas funded by The Whiteley Clinic andwas performed at our Whiteley Clinic, Guildford.The researcher, Briony Hudson,was supervised by Prof Jane Ogden at The University of Surrey and Prof Mark Whiteley. Her workhas been submitted to the University of Surrey and shewas awarded her PhD in Autumn 2014.The workis going to be published:
- Hudson BF, Ogden J, Whiteley MS. Randomised Controlled Trial to Compare the Effect of Simple Distraction Interventions on Pain and Anxiety Experienced During Conscious Surgery. European Journal of Pain. 2015.
An interdisciplinary primary care model ideal setting to promote physical activity as medicine
To better understand the current use of physical activity as medicine among Family Health Teams (FHTs) in Ontario, researchers at the Department of Kinesiology at the University of Waterloo and the Centre for Family Medicine Family Health Team conducted an environmental scan of 102 FHTs. They published their findings today in the journalApplied Physiology, Nutrition, and Metabolism.
Family Health Teams (FHTs) are part of a shift towards a multidisciplinary primary care model that addresses the healthcare needs of a community by allowing different healthcare professionals to work collaboratively under one roof. Currently, FHTs serve a relatively small percentage of Ontarians; however, their multi-disciplinary structure may create an ideal environment to enable physical activity promotion as most Canadians receive healthcare though the primary care system. Physical activity has well-established health benefits; however, the best way to engage Canadians in an active lifestyle remains largely unknown.
Before this environmental scan, the number and types of physical activity promotion services, and the types of professionals providing physical activity counselling in Ontario FHTs was not known .
The researchers found that almost 60% of responding FHTs in Ontario offered a physical activity service. However, the types, durations and targeted populations of the services varied depending on the individual FHT. Physical activity services were often restricted to people with specific conditions or needs rather than available to all individuals.
According to the study, “many different types of allied health professionals were facilitating physical activity services. The diversity in the qualifications is concerning, as it suggests that individuals providing physical activity therapy do not always have qualifications related to physical activity prescription and counselling.”
Cameron Moore, from the Department of Kinesiology at the University of Waterloo and co-author of the study said, “It is promising that almost 60% of responding FHTs offered a physical activity service. However, continued efforts are needed to increase the accessibility and standardization of physical activity therapy offered though primary care.“
“In Ontario, Kinesiology is a newly accredited professional designation with a scope of practice that includes physical activity promotion and prescription. We feel that physical activity counsellors who are Registered Kinesiologists with expertise in physical activity prescription and behavior change counselling are ideally suited as primary care providers in FHTs.”
The article “Physical Activity as Medicine among Family Health Teams: An Environmental Scan of Physical Activity Services in an Interdisciplinary Primary Care Setting” was published today in Applied Physiology, Nutrition, and Metabolism.
Health economics helps insurers, health care systems and providers make treatment decisions based on the cost of extra “units” of health arising from a specific treatment. By calculating the cost for each year of life or quality-adjusted year of life gained, these groups can decide whether changing treatments or adding in a new treatment beyond the existing standard of care is “worth it.”
However, while the resulting incremental cost effectiveness ratio (ICER) is often presented as an absolute measure upon which to base these decisions, an opinion published by University of Colorado Cancer Center researchers D. Ross Camidge, MD, PhD, and Adam Atherly, PhD, suggests that the consumers of these data need to be much more aware of the assumptions underlying these calculations.
“Increasingly physicians are being presented with health economic analyses in mainstream medical journals as a means of potentially influencing their prescribing. However, it is only when you understand the multiple assumptions behind these calculations that you can see that they are by no means absolute truths,” Camidge says.
The Therapeutic Paradox: What’s Right for the Population May Not Be Right for the Patient By SCOTT ABEREGG, MD
“An article in this week’s New York Times called Will This Treatment Help Me? There’s a Statistic for that highlights the disconnect between the risks (and risk reductions) that epidemiologists, researchers, guideline writers, the pharmaceutical industry, and policy wonks think are significant and the risks (and risk reductions) patients intuitively think are significant enough to warrant treatment….
- Evaluating Health Information (jflahiff.wordpress.com)
- How to Read a Research Paper (jflahiff.wordpress.com)
- Research Articles Summarized for us All (jflahiff.wordpress.com)
In Washington, sometimes the most significant developments quietly creep up on you. No epic debate or triumphant bill-signing ceremony, but rather a collection of seemingly small events begin to tip the scales.
That’s what is happening today with telehealth. Almost under the radar, federal and state officials have been giving a much-needed push in support of virtual care. Though the technology has long existed, until recently the money had not followed. And sadly in our current fee-for-service healthcare system, little gets done without a payment code, even if it makes eminent medical and economic sense.
Consider some of the recent action. In November, the Department of Agriculture released more than $8.5 million in health-related grants to 31 recipients in rural communities. Many are using the money to purchase telehealth equipment such as high-quality cameras and broadband Internet.
The previous month the federal government issued rules expanding Medicare payment for a range of telehealth services. Caregivers can earn about $42 per month for chronic care management under the new regulations. Seven new procedure codes were also added, covering such services as annual wellness visits and psychotherapy.
And the end-of-year spending bill approved by Congress designates more than $26 million for telemedicine programs largely in rural communities and through the Veteran’s Administration.
Legislation filed in the new Congress would continue the trend loosening anti-kickback restrictions for the purchase of telemedicine equipment and requirements that physicians receive a separate license to practice in each state (a major barrier for doctors aiming to deliver virtual care to patients across the nation.)
Consumers can’t wait. Nearly 40% of 1,000 adults nationwide surveyed by PwC’s Health Research Institute say they would be willing to have an appointment with a physician via smartphone, representing a potential $42.1 billion market. Significant percentages of American consumers indicate they are eager for virtual care alternatives such as a device that attaches to a mobile phone, snaps an image of an ear canal or rash and transmits it to a physician for an instant reading.
- What is Telemedicine (American Telemedicine Association)
- Telehealth (US Department of Health and Human Services)
“The Role of Telehealth in an Evolving Health Care EnvironmentInstitute of Medicine report (11/20/2012)Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.HRSA works to increase and improve the useoftelehealth to meet the needs of underserved people by:
- Fostering partnerships within HRSA, and with other Federal agencies, states and private sector groups to create telehealth projects.
- Administering telehealth grant programs.
- Providing technical assistance.
- Evaluating the use of telehealth technologies and programs.
- Developing telehealth policy initiatives to improve access to quality health services.
- Promoting knowledge exchange about “best telehealth practices.” “
- Telemedicine (Medicaid.gov)
“Provider and Facility GuidelinesMedicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states have enacted legislation that requires providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the state are binding under current Medicaid rules.”
- Ohio Department of Rehabilitation and Correction Telemedicine
“Since itsinception, the Telemedicine program has conductedapproximately 19,000 consultations. Approximately 5000 such consults in 12 different medical specialties are now completed each year. Medical careis initiated at the local prison by the nurses and physiciansonsite. Telemedicine is then used to present the inmate and his or her medical condition to the specialty physicians at The Ohio State University Medical Center forappropriate care. In addition to the medical services provided by theOSUMC,ODRC staff conduct psychiatric and dietary consultations from a Central Office video systemlocated in the Office of Correctional Health Care. Thirty-two prisonsparticipate in the Telemedicine program.The Telemedicine network is part of a larger ODRC videoconferencing network that also includes the Division of Parole and Community Services’ eight regional offices and 3 district offices. The prison school system known as the Ohio Central School System has 6 distance learning centers included on the network as well. Thus, the videoconferencing network is used to not only to provide improved access to specialty care, but also continuing education to health care, administrative, security, and other support staff, as well as legal hearings, parole board hearings, administrative meetings, and patient transfer meetings.”
- Telemedicine at UPMC (University of Pittsburg Medical Center)
“The UPMC Telemedicine Program connects small or rural community hospitals and outpatient locations to specialists at UPMC, allowing patients to receive world-class care close to home.
From the 30 January 2015 post BY at Covering Health – Monitoring the Pulse of Healthcare Journalism
White House has announced its anticipated “Precision Medicine Initiative,” which it describes as an “emerging field of medicine that takes into account individual differences in people’s genes, microbiomes, environments, and lifestyles – making possible more effective, targeted treatments for diseases like cancer and diabetes. ”
The practice of medicine has always been personal regarding the treatment of individual patients, but science has fostered a new era of so-called personalized medicine that takes into account each person’s specific clinical, genetic, genomic and environmental information in designing tailored treatment plans
The White House released this fact sheet today.
The White House released this fact sheet today.
- Five Accelerants to the Adoption of Connected Health (From the 28 January 2015 item at The cHealth blog)
“I have been thinking lately about the cultural and business phenomena that are currently shaping and accelerating the adoption of connected health and, in that context, came up with five accelerants. The best part of the story is that four of the five are already going on and we can see their early-stage effects.
So, at the risk of ‘dumbing down’ adoption, here is my list of five accelerants. If we could make these go faster, the adoption of connected health would accelerate too.”
1. Increase value-based reimbursement for providers.
2. Create more mechanisms for provider reimbursement for non face-to-face care (like the new CMS CPT code that just took effect).
3. Accelerate consumer choice in the marketplace as well as ‘consumer-driven health care’ (i.e., high deductible plans, health savings accounts (HSAs), etc.).
4. Make the consumer-facing technology truly frictionless.
5. Create a universal privacy/security technology and make it a public good.
Integrated approach to customer relationship management and patient relationship management (From the 28 January 2015 post at Health Care Conversation)
A comprehensive consumer and patient engagement model should help providers attract and engage individuals in the key areas they value:
- Help in understanding and navigating the health care system
- Personalize information and care based on an individual’s needs
- Easy access and communication with provider and care team
- Support in managing an acute episode or a chronic illness
- Secure access to personal health records
Unnecessary care that’s not evidence-based—usually associated with excess testing, surgical procedures or over-prescribing—accounts for up to 30% of what is spent in healthcare. In recent months, enforcement actions against physicians and hospitals have gained increased attention. But unnecessary care and over-utilization is not a new story or one that’s easy to understand.
Medical necessity means something slightly different in every part of the healthcare industry. Varied definitions and interpretations are used by providers, physicians, courts, pharmacy benefits managers, government insurers, private insurers, and consumers. Perhaps the two most important are from the largest and most influential payer, Medicare, and the industry’s most important clinical authority, the American Medical Association (AMA).
The AMA defines medical necessity as: “Healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other healthcare provider.” “Statement of the American Medical Association to the Institute of Medicine’s Committee on Determination of Essential Health Benefits,” American Medical Association, January 14, 2011
So based on these definitions, the application of “medical necessity” leaves lots of room for variation in how doctors and hospitals determine what’s done, and how payers (Medicare, Medicaid, employers, individuals) assess the appropriateness of their activities and costs. Therein is the conundrum about medical necessity and unnecessary care and the need for fresh thinking about the issue.
The basic facts:
Over-utilization and unnecessary care is prevalent and costly: Several reputable studies point to systemic over-utilization costing the U.S. system up to 30% more than what’s necessary (Exhibit A). The U.S. health system is the world’s most expensive, and health costs, per the Congressional Budget Office, will continue to increase at least 2-3% faster than the overall economy for the next decade. The costs associated with unnecessary care (a.k.a. medical necessity) are significant and growing. “The 2014 Long-Term Budget Outlook,” Congressional Budget Office, July 2014.
The government is cracking down on unnecessary care: Hospitals are increasingly being held accountable for the practice patterns of the physicians on their medical staff via the False Claims Act. Enforcement actions against both are on the rise and financial penalties harsh (see Exhibit B for recent cases).
Media attention is sparking public attention to unnecessary care: The Wall Street Journal calls its series, “Secrets of the System.” National broadcast and print news organizations have increased coverage of healthcare including its tendencies around medical necessity and unnecessary care. And social media is a hotbed for anecdotal assessments of “medical necessity”—some supported with objective data, most supported by personal experience, and a few judiciously studied and reported.
So if health costs are a looming problem in U.S. healthcare, and lack of consistency around the delivery of medically-necessary care is a systemic challenge that’s increasingly transparent, why isn’t more done? Most industry insiders offer these reasons:
The body of scientific evidence about what works best is expanding and changes fast. There are 20,000 medical journals. Keeping track of the latest innovations is almost impossible without using a clinical knowledge management software program that captures and filters relevant information useful to making patient diagnostic treatment decisions.
The strength of evidence about what works best and why is often weak. As more information about a patient’s signs, symptoms, risk factors and co-morbidities are factored into a treatment determination, the less likely it is that a clear “medical necessity” directive is found. Ironically, the more information (data) a clinician has about a specific patient, the less likely it is that a “medically necessary service” is dictated through a clinical algorithm or guideline.
Most consumers assume everything recommended is “medically necessary.” The majority of consumers assume that what their physician recommends is evidence-based, and few feel confident to challenge their view. Therefore, consumers want MORE not less in the majority of cases. And social media and media coverage is complicating matters as treatments-de jour become more widely known to consumers searching the latest and best treatments. The burden to stay abreast about traditional and nontraditional methods for diagnosing and treating is daunting, especially if reimbursements are cutting into time spent with patients.
Most providers necessarily err on the side of over-treatment. The majority of physicians and the institutions that credential them to practice tend to over-treat fearing liability exposure or the possibility of an inaccurate diagnosis. It’s precautionary and a business imperative (discounting it can be lucrative at the same time).
The health information technology tools that allow for real-time, accurate matching of a patient’s signs, symptoms, risk factors and co-morbidities to the latest and best evidence don’t exist or are too expensive. The integration of smart medical record systems shared by clinically-integrated networks and with their patients is still aspirational in most communities. These systems are expensive. Clinicians doubt that these systems will pay for themselves in improved efficiency (less paperwork), nor do they trust that payers will pay them more if they make the investment. And most consumers aren’t demanding them to make the investment. Instead, basic access, convenient locations and an assuring experience with doctor are of higher importance.
These views provide a defensible rationale as to why medical necessity and unnecessary care is a systemic challenge in our system, but in coming months, they may be seen more as lame excuses. The spotlight on unnecessary care and medical necessity is likely to shine brighter because:
Unnecessary care contributes significantly to the impressive profitability in many parts of the health system.
Unnecessary care can be harmful to consumers.
The data and sophisticated analytic tools upon which determinations of medical necessity and unnecessary care are increasingly available. Defaults that “my patients are different” and “we don’t have the data” will fall on deaf ears.
What does it mean?
Documentation is key. Accurate clinical documentation across sites and systems of care is table stakes.
Transparency about medical necessity and unnecessary care is assured. Data about the performance of every practitioner, hospital, and health system will be widely accessible. And the evidence supporting coverage and denial decisions by insurers, formulary design by Pharmacy Business Managers (PBMs) and benefits managers, and the justification for narrow networks will be equally available.
From the 28 January 2015 post at Engineering Evil – Intel Portal for Weighted Data and Information
In some US health plans, HIV drugs cost nearly $3,000 more per year than in other plans. If left unchecked, this practice could partially undermine a central feature of the Affordable Care Act.
Harvard School of Public Health
Boston, MA — Some insurers offering health plans through the new federal marketplace may be using drug coverage decisions to discourage people with HIV from selecting their plans, according to a new study from Harvard T.H. Chan School of Public Health. The researchers found that these insurers are placing all HIV drugs in the highest cost-sharing category in their formularies (lists of the plans’ covered drugs and costs), which ends up costing people with HIV several thousands more dollars per year than those enrolled in other plans.
But I did want to share a few links to some of the more thoughtful (or provocative) articles and reviews, representing critics on both the left and right. I also wanted to draw your attention to another recent book providing a conservative perspective on health reform.
- Here’s a Sunday New York Times book review by Zephyr Teachout.
- Here’s Malcolm Gladwell in the New Yorker.
- And Peter Orszag (who was in the Obama administration when the bill was being written and appears in the book) at Bloomberg View writes about what he thinks Brill got wrong.
- Avik Roy at Forbes has a conservative perspective.
The second book (and I should say that while I have a copy, I loaned it to a colleague before I read it myself…) is by the Washington Examiner‘s commentary editor, Philip Klein, who looks at the options and thoughts on the right in “Overcoming Obamacare: Three Approaches to Reversing The Government Takeover of Health Care.” It hasn’t been as widely reviewed as Brill’s book but Aaron Carroll gives it an interesting write-up in the Incidental Economist blog.
One of our neighbors died 5 years ago. She hid her symptoms from her family. Wondering if she would be alive today if she would have been proactive.
26 January 2015, Cancer Research UK
People who dismiss their symptoms as trivial or worry about wasting the doctor’s time may decide against going to their GP with red-flag cancer warning symptoms, according to a Cancer Research UK study* published in the British Journal of General Practice (link is external)today.
“Many of the people we interviewed had red flag symptoms but felt that these were trivial and didn’t need medical attention, particularly if they were painless or intermittent.” – Dr Katriina Whitaker
Others might decide not to get possible cancer symptoms checked out because they fear a cancer diagnosis, they adopt a stiff upper lip, they lack confidence in the healthcare system, or they think their problem is down to ageing.
Researchers in London and Hull** looked at how people who experience possible cancer symptoms decide whether or not to seek medical help. They sent out a health survey that was completed by more than 1,700 people, aged 50 and over, from three London GP practices.
The survey specifically did not mention cancer, but incorporated a list of 17 symptoms including 10 cancer ‘alarm’ warning signs, such as persistent cough or hoarseness, unexplained lump, persistent change in bowel or bladder habits, and a sore that does not heal.***
More than 900 people reported having at least one alarm symptom during the past three months. Researchers carried out in-depth interviews with almost 50 of them, almost half (45 per cent) of whom had not seen their GP about their symptoms. ****
One woman with persistent abdominal pain did not go for a recommended test. She said: “At times I thought it was bad … but when it kind of fades away, you know, it doesn’t seem worth pursuing really.” A man, who experienced a persistent change in bladder habits, said: “You’ve just got to get on with it. And if you go to the doctor too much, it’s seen as a sign of weakness or that you are not strong enough to manage things on your own.”
Dr Katriina Whitaker, a senior research fellow at University College London during the study, said: “Many of the people we interviewed had red flag symptoms but felt that these were trivial and didn’t need medical attention, particularly if they were painless or intermittent.
“Others felt that they shouldn’t make a fuss or waste valuable NHS resources. The stiff-upper-lip stoicism of some who decided not to go to their doctor was alarming because they put up with often debilitating symptoms. Some people made the decision to get symptoms checked out after seeing a cancer awareness campaign or being encouraged to do so by family or friends – this seemed to almost legitimise their symptoms as important.”
Reasons people gave for deciding to seek help included symptoms not going away, instinct that something was not right, and awareness or fear that they might have cancer. A man with an unexplained throat lump said: “But always at the back of your mind you’ve always got the fear of cancer …….. well it’s best to check just in case.” However, fear also made some people decide not to check out symptoms, or if symptoms did persist some people began to think they were normal for them.
Some people waited for another reason to visit their GP and mentioned the cancer alarm symptom then. Others said they would rather use an emergency route, such as going straight to A and E, than wait to see a specialist after being referred by their GP.
Dr Richard Roope, Cancer Research UK’s GP expert, said: “The advice we give is: if in doubt, check it out – this would not be wasting your GP’s time. Often your symptoms won’t be caused by cancer, but if they are, the quicker the diagnosis, the better the outcome. Seeking prompt advice from your GP about symptoms, either on the phone or during an appointment, could be a life-saver, whatever your age. And the good news is that more than half of all patients diagnosed with cancer now survive for more than 10 years.”
From the 22 January 2015 post
Of the many hidden gems in the Affordable Care Act, one of my favorites is Physician Compare. This website could end up being a game changer—holding doctors accountable for their care and giving consumers a new way to compare and choose doctors. Or it could end up a dud.
The outcome depends on how brave and resolute the Centers for Medicare and Medicaid Services (CMS) is over the next few years. That’s because the physician lobby has been less than thrilled with Physician Compare, and, for that matter, with every other effort to publically report measures of physician performance and quality.
I’d give CMS a C+ to date. Not bad considering it’s the tough task. The agency has been cautious and deliberate. But after the many problems with Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare—not to mention the shadow of healthcare.gov’s initial rollout—that’s understandable. They want, I hope, to get this one right from the get-go. And competition from the private sector looms.
Congress mandated that CMS establish Physician Compare by Jan. 1, 2011 and that an initial content plan be submitted by Jan. 1, 2013. CMS met those deadlines, albeit with a rudimentary site that launched in late December 2010. The agency updated its plans in 2013 and 2014, even as it added more content and functionality to the site.
The law requires the site to have “information on physician performance that provides comparable information on quality and patient experience measures.” That’s to include measures collected under the Medicare Physician Quality Reporting System (PQRS), Medicare’s main quality reporting vehicle, and assessments of:
- patient health outcomes and the functional status of patients
- continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
- the efficiency of care
- patient experience and patient, caregiver, and family engagement
- the safety, effectiveness, and timeliness of care
Notably, Congress set no deadline for the site to meet those specifications or be fully operational.
So what’s posted so far? The centerpiece of the site is a searchable directory of some 850,000 Medicare providers. That includes most of the practicing doctors in the U.S. with the exception of pediatricians and other physicians who don’t treat Medicare patients. This database predates the ACA and Physician Compare but its functionality, reliability and accuracy (a big complaint from physician groups) is being gradually enhanced.
Each doctor has his or her own profile page—a significant foundation that could accommodate quality and patient experience data in the future.
Consumers can also search three additional databases on the site. They identify doctors and other clinicians who participate in (a) PQRS; (b) the Electronic Prescribing Incentive Program; and (c) the electronic health record (EHR) incentive program (also called the meaningful-use program). About 350,000 physicians and other clinicians participate in the latter.
The bad news: these databases are separate and their content is not integrated. That makes searching for information on a particular group practice or individual doctor cumbersome and time consuming. And the databases aren’t user-friendly. On the plus side, for researchers and health administrators, the databases are downloadable.
The last of four Florida insurers blasted by AIDS activists for the high cost of their HIV drugs relented last week, saying it would cap what patients pay every month for four types of medication.
“We will voluntarily agree to set an out-of-pocket limitation of $200 per month on each of the following drugs: Atripla, Complera, Stribild, and Fuzeon,” Preferred Medical Plan CEO Tamara Meyerson wrote to Kevin McCarty, commissioner of the Florida Office of Insurance Regulation, in a Jan. 14 letter.
The other three companies — Coventry Health Care, Humana and Cigna — had earlier reached formal agreements with state regulators to lower their prices and to fill prescriptions without prior authorization for 2015.
Preferred did not violate Florida’s anti-discrimination laws, said Amy Bogner, a spokeswoman for the state’s insurance office.
An estimated 120,000 Floridians have HIV, and nearly half of them live in South Florida, according to state data.