Category: Health Care Quality

Giving “Insanity” a Whole New Meaning

This is from The Wall Street Journal:

woman-scaredInside the U.S. Department of Health and Human Services sits an agency whose assignment since its creation in 1992 has been to reduce the impact of mental illness and target services to the “people most in need.” Instead the Substance Abuse and Mental Health Services Administration, known as Samhsa, uses its $3.6 billion annual budget to undermine treatment for severe mental disorders…

For instance, Samhsa’s Guide to Mental Illness Awareness Week suggests schools invite as speakers such radical organizations as MindFreedom, which rejects the existence of mental illness and stages “human rights” campaigns against drug treatment and commitments. Or the National Coalition for Mental Health Recovery, which “holds that psychiatric labeling is a pseudoscientific practice of limited value in helping people recover.”

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Apr 03, 2014 | 16 comments | by

I Guess the British NHS Was an Exception

This is David Blumenthal, former national coordinator for health information technology, interviewed by James Fallows in The Atlantic:

Laptop and StethoscopeWhen the benefits of using better technology are “internalized,” as the economists would say, there has been much more rapid, complete, and effective adoption of electronic medical records. So, the VA: the benefits are internalized, because the VA has to live within a budget. In private health-care organizations like Kaiser or the Geisinger plan in Pennsylvania, or the Group Health Cooperative in Puget Sound, electronic medical records were adopted decades ago, and are widely used and highly effective.

Here is Linda Gorman on health IT in the National Health Service.

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Mar 28, 2014 | 14 comments | by

The Medieval Guild Lives On

LawiStock_000005825665XSmalls concerning nurse practitioners (NPs) vary across states, but the three biggest regulations that affect NPs are those that limit their ability to write prescriptions, to practice independently and to receive direct reimbursement from insurers:

  • When doctors are required to supervise NPs when prescribing controlled substances, physician wages increase by 7 percent while nurse practitioner wages decrease by 14 percent.
  • Those restrictions also increased the number of physician hours worked by 6 percent to 9 percent while decreasing the number of hours worked by nurse practitioners by 6 percent to 14 percent.
  • The price of a well-child medical exam rises by 3 percent to 16 percent due to these laws.

However, none of these regulations appeared to reduce infant mortality rates or malpractice premiums

Source: NBER Working Paper.

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Mar 28, 2014 | 17 comments | by

Pay for Performance Fails Again, and Again, and Again

Aaron Carroll writes:

Hand Holding Paper CurrencyI’m getting to be a broken record in my skepticism about pay for performance. Here, here, here, here, here, and here just to name a few posts. But there’s another study out in the Annals of Surgery, “Does Pay-for-Performance Improve Surgical Outcomes? An Evaluation of Phase 2 of the Premier Hospital Quality Incentive Demonstration“

…This study involved nearly a million procedures in 12 states over six years. They tried to reduce severe complications and mortality within 30 days. Did paying for performance work?

While mortality went down over time, it didn’t go down faster in the P4P hospitals than the non P4P hospitals. There were no great improvements in complications, and there were no great improvements in mortality. Even in the worst 20% of hospitals (where there is the most room for improvement), P4P was not associated with great improvements over non P4P.

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Mar 20, 2014 | 10 comments | by

Uninsured Trauma Patients Get Better Care than Insured

Why? Perhaps because non-trauma community hospitals would prefer to have insured rather than uninsured patients. So, uninsured patients are more likely to be transferred to trauma centers, where they are likely to get better care.

According to Kit Delgado, and colleagues, presenting research results in JAMA Surgery, both privately insured and Medicaid patients were significantly more likely (11 percent and 14 percent more) to be admitted to a non-trauma hospital than transferred.

Their conclusion:

Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma inter-hospital transfers and outcomes at the population level are warranted.

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Mar 19, 2014 | 8 comments | by

So Why Don’t We Speed Up Approvals And Save More Lives?

This is from an NBER Working Paper by Frank Lichtenberg:

prescription-bottleWe investigate the effect of the vintage (year of FDA approval) of the prescription drugs used by an individual on his or her survival and medical expenditure. When we only control for age, sex, and interview year, we estimate that a one-year increase in drug vintage increases life expectancy by 0.52%. Controlling for other variables including activity limitations, race, education, family income as a percent of the poverty line, insurance coverage, Census region, BMI, smoking and over 100 medical conditions has virtually no effect on the estimate of the effect of drug vintage on life expectancy.

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Mar 19, 2014 | 11 comments | by

Surgical Checklists Don’t Save Lives

Atul Gawande has become famous for The Checklist Manifesto, which makes the case for delivering medical care like The Cheesecake Factory delivers cheesecake. However, David R. Urback and colleagues reported these results:

Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications…

During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29).

Atul Gawande responds to the checklist study. So does Aaron Carroll.

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Mar 17, 2014 | 12 comments | by

From the Comments: Cookbook Medicine Can Work

This is Larry Wedekind:

Cookbook medicine, as you put it, is an essential innovation of the 20th century that is saving lives every day in every part of the country. Cookbook Medicine contributed to my procedural success in my surgery as well as the art that my surgeon employed to produce a favorable outcome. When Cookbook Medicine (standardized clinical diagnoses and approaches, tests, and procedures) is required by government in all cases, then recognition of patient (human) differences suffers and this must NEVER be allowed. I totally agree with Charlie’s statement that Pilot Projects that reward innovation and results are worthwhile and needed in the healthcare arena.

I do have the general answer as to why most Pilot Projects have failed to produce the results that were sought by the government. These Pilot Projects do not typically involve any risk for the recipients of the grants that enable these Pilots. Note that when my company is enabled to embark upon a new venture, we typically assume significant financial risk and are rewarded if we succeed in accomplishing the stated goals. This is highly motivational.

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Mar 13, 2014 | 12 comments | by

Nursing Homes Are Dangerous Places

One-in-three patients in skilled nursing facilities suffered a medication error, infection or some other type of harm related to their treatment, according to a government report released today that underscores the widespread nature of the country’s patient harm problem.

Doctors who reviewed the patients’ records determined that 59 percent of the errors and injuries were preventable. More than half of those harmed had to be readmitted to the hospital at an estimated cost of $208 million for the month studied — about 2 percent of Medicare’s total inpatient spending. (Propublica)

HT: Jason Shafrin.

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Mar 07, 2014 | 4 comments | by

No Uniformity in Health Care for Wounded Warriors

The Army, for example, requires the soldier to have had a medical condition “that demanded at least six months of complex medical management,” while the Marine Corps standard was that the individual had “to have medical conditions that demanded treatment for more than 90 days.”

The Air Force requires an injury or illness that is combat ― or hostilities ― related, requiring an unspecified amount of long-term care and a medical evaluation board or physical evaluation board to determine fitness for duty. The Navy has a similar standard. (Walter Pincus)

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Feb 26, 2014 | 14 comments | by
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