The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. GB Shaw
Saturday, March 26, 2011
Are you better off flying with a trainee pilot, or being operated on by a trainee surgeon?
One of the concerns that some people have relates to the way we train our doctors, essentially an apprenticeship system, with a trainee learning from a senior doctor. While I have some concerns about other aspects of this system, one of the unavoidable consequences is that trainees have to practice upon a patient. Is this safe? Surely being operated on by someone with less expertise increases the risk of something going wrong?
A study has just been published seeking to answer that question. The American College of Surgeons examined patient outcomes in more than 600,000 operations. They found that having a resident, (junior surgeon in training) while associated with a slightly higher risk of developing (usually minor) complications, was also more likely to be associated with a slightly reduced risk of death. The reasons obviously are unclear, but this important paper does provide some reassurance.
A study has just been published seeking to answer that question. The American College of Surgeons examined patient outcomes in more than 600,000 operations. They found that having a resident, (junior surgeon in training) while associated with a slightly higher risk of developing (usually minor) complications, was also more likely to be associated with a slightly reduced risk of death. The reasons obviously are unclear, but this important paper does provide some reassurance.
Wow, Oh Wow
That was Muir Grays Twitter post on seeing this weeks BMJ. Apart from the papers referenced below (Reducing Variation March 24th), there are a number of other papers worth checking out. A report from the Netherlands again finds a marked variation in utilization of medical interventions. An editorial on variation in the NHS; a look at how to redevelop care for long term conditions, and a lot more.
Why such emphasis on variation? Surely the areas with low utilization will balance out the high users for a zero sum game. This is unlikely to be the case, there is mounting evidence, mainly from the US, but also from other countries, that outcomes are not affected by the amount of care given above a certain amount. Therefore there are huge opportunities for reducing waste, saving money, and a lot more good stuff.
Why such emphasis on variation? Surely the areas with low utilization will balance out the high users for a zero sum game. This is unlikely to be the case, there is mounting evidence, mainly from the US, but also from other countries, that outcomes are not affected by the amount of care given above a certain amount. Therefore there are huge opportunities for reducing waste, saving money, and a lot more good stuff.
Thursday, March 24, 2011
Eliminate Variation, Part 2
A piece in the BMJ by John Wennberg summarizes much of the knowledge around variation in medical practice. He breaks unwanted variation into three categories, effective care, preference sensitive care and supply sensitive care.
- Effective care. This is care that is the right treatment for the vast majority of patients, and variation in this element relates to underuse, e.g. vaccination
- Preference Sensitive Care. This is care provided when there are more than one effective treatment, and choice of therapy should be dictated by patient preference; in fact, physician choice often determines this. Mastectomy rather than lumpectomy plus radiation for breast cancer for example.
- Supply sensitive care. This is care that is dependent on the supply of services in a region. Roehmers law is one example of this; this states that in an insured popualtion, a hosoital bed is a filled bed. Dartmouth have found no corrleation between the amount of care received and outcomes, suggesting that there are areas with massive overuse of resources. Gawande in a brilliant article two years ago examined this discrepancy.
Also check out the NHS health Atlas. There are huge variations in care evident. Likely that this occurs everywhere.
Eliminate Variation
One of the godfathers of determining the extent of variation in medical practice and founder of the Dartmouth Health Atlas, Jack Wennberg, has recently published a book, "Tracking Medicine", available here. I have just downloaded it, will review it when finished, but it gets a great review here.
Wednesday, March 23, 2011
The Future of Nursing
Medicine is excessively hierarchical. That is pretty obvious. While there may have been some benefit to this in the past, (though I am at a loss to think what that might be), clearly healthcare must be seen as a team effort. The role and contribution of nurses in delivering more and more effective healthcare has not been utilized to anything like its full potential. From the Future of Nursing, comes the following recommendations;
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
- Effective workforce planning and policy making require better data collection and an improved information infrastructure.
Reform of Public Service
This is the subject of a special survey in this weeks Economist. While looking at public services generally, criticizing (rightly in my opinion) the growth and low productivity of services worldwide, it has a specific mention of health. Well worth reading.
Amongst the figures given; "McKinsey points out that American spending on this has grown at an annual lick of 4.9% over the past 40 years, whereas GDP per person has grown by just 2.1%. Pessimists are convinced nothing can be done to restrain it. A refreshingly different perspective is provided by Sir John Oldham, a British doctor who is clinical lead for productivity in the National Health Service."
"America, which currently spends 16% of its GDP on health care is theoretically on track to spend 100% of its GDP on health care by 2065."
"America, which currently spends 16% of its GDP on health care is theoretically on track to spend 100% of its GDP on health care by 2065."
Tuesday, March 22, 2011
Spring
What is medical harm?
My favorite definition, from a good friend, (Thanks Peter) is that harm is anything that you would not want happen to you or your family.
Some Thought on Value in Healthcare
Value is a dirty word in healthcare, conjuring up visions of ruthless bean counters, scrabbling for pennies while patients suffer. How different though is the reality? Regardless of location, healthcare costs are rapidly climbing, disease burdens, therapies, diagnostics and expectations are rising faster. Like it or not, hard choices must be made, if not by clinicians, then by the payer, ultimately the taxpayer. How does one align this imperative with the need to ensure quality of care is optimized?
A recent paper by former colleagues of mine brought home the reality of this dilemma. Cruz et al sought to improve compliance with goal directed therapy for children with sepsis. They demonstrated a marked reduction in time to first fluid and antibiotic administration, consistent with guideline recommendations. However, part of the solution was to deploy extra nursing, pharmacy, medical and EMT staff. While this may well have been a beneficial use of this scarce resource, it is unclear if the value increased.
Value can be defined as health outcomes (quality) divided by the cost of achieving those outcomes. So while quality almost certainly increased, it is likely that the cost of achieving this level of quality also increased. The question that must be asked, could better or more health outcomes be achieved for the same expenditure. Unfortunately our measurement systems are as yet unable to answer this question. For a more detailed discussion around this topic, please see Michael Porters website.
A recent paper by former colleagues of mine brought home the reality of this dilemma. Cruz et al sought to improve compliance with goal directed therapy for children with sepsis. They demonstrated a marked reduction in time to first fluid and antibiotic administration, consistent with guideline recommendations. However, part of the solution was to deploy extra nursing, pharmacy, medical and EMT staff. While this may well have been a beneficial use of this scarce resource, it is unclear if the value increased.
Value can be defined as health outcomes (quality) divided by the cost of achieving those outcomes. So while quality almost certainly increased, it is likely that the cost of achieving this level of quality also increased. The question that must be asked, could better or more health outcomes be achieved for the same expenditure. Unfortunately our measurement systems are as yet unable to answer this question. For a more detailed discussion around this topic, please see Michael Porters website.
Boeing to the Rescue?
A recent piece in JAMA by Pronovost is well worth reading. In it he contrasts the way we design (or rather fail to design) healthcare, especially in relation to equipment, (haphazard, no systems thinking, individuals insisting on their preferred piece of technology etc) versus the way airlines buy planes. They do not buy planes, each of which has different toilets seats, lifebelts etc. They buy a standard plane, for economic as well as safety (reduce variation ) reasons. He suggests in an American context that what is needed is a systems integrator, similar to Boeing. It is interesting that national healthcare systems, despite being in a better position to act in this way, singularly fail to do so.
I have worked in intensive care units where the number of different types of ventilator exceeded the daily census of ventilated children; where the choice of a specific ventilator that a child was placed on depended on which physician was on call. This type of variability is hugely damaging, expensive, a safety risk and results in poor training. Compounding this is a perceived need for hospitals to get the latest new thing, often resulting in a situation where there are insufficient patient numbers to allow all team members to develop the required expertise and experience which are necessary to deliver the best outcomes.
While I agree with his arguments, I think he fails to develop the logical conclusion, in that the entire system, inside and outside hospitals needs to be standardized as much as possible.
I have worked in intensive care units where the number of different types of ventilator exceeded the daily census of ventilated children; where the choice of a specific ventilator that a child was placed on depended on which physician was on call. This type of variability is hugely damaging, expensive, a safety risk and results in poor training. Compounding this is a perceived need for hospitals to get the latest new thing, often resulting in a situation where there are insufficient patient numbers to allow all team members to develop the required expertise and experience which are necessary to deliver the best outcomes.
While I agree with his arguments, I think he fails to develop the logical conclusion, in that the entire system, inside and outside hospitals needs to be standardized as much as possible.
Monday, March 21, 2011
Psst, want to buy a cheap electronic medical record?
Beginning in the 70's, the Veterans Administration developed an in-house electronic medical record, (EMR), now termed VISTA, which has a number of attractive features as outlined. Notably it is free, which given the financial challenges facing this country is not to be sneezed at.
Features
VISTA includes computerized order entering, barcode administration, electronic prescribing and clinical guidelines. UPTODATE can be accessed from within the system. It also allows (at least for the Veteran population) patients to access their own medical records, similar to the KP system. Vista Imaging allows integration of PACS, pathology, EKG etc. the VISTA system has been used in conjunction with telemedicine to provide surgical care to rural Western States.
Achievements
VA claims a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms the vast majority of public hospitals, supposedly based on its EMR implementation. There are only three hospital systems in the US, which have achieved HIMSS stage 7, (the highest level of IT implementation), one of which is the VA. A non-VA hospital using VISTA is one of only 42 US hospitals to achieve HIMS level 6.
Implementation
Approximately 50% of US hospitals with a full EMR implementation are VA hospitals using Vista. It has also been implemented worldwide, including Finland, Germany, and Denmark as well as developing nations.
Cost
As it is open source, the license is free. Obviously there are large costs relating to localization, hardware, training, and implementation. I have found one reference to implementation of VISTA over 8 hospitals in one state costing $9 million, as compared to a commercial installation over the same number of hospitals costing $90 million.
Features
VISTA includes computerized order entering, barcode administration, electronic prescribing and clinical guidelines. UPTODATE can be accessed from within the system. It also allows (at least for the Veteran population) patients to access their own medical records, similar to the KP system. Vista Imaging allows integration of PACS, pathology, EKG etc. the VISTA system has been used in conjunction with telemedicine to provide surgical care to rural Western States.
Achievements
VA claims a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms the vast majority of public hospitals, supposedly based on its EMR implementation. There are only three hospital systems in the US, which have achieved HIMSS stage 7, (the highest level of IT implementation), one of which is the VA. A non-VA hospital using VISTA is one of only 42 US hospitals to achieve HIMS level 6.
Implementation
Approximately 50% of US hospitals with a full EMR implementation are VA hospitals using Vista. It has also been implemented worldwide, including Finland, Germany, and Denmark as well as developing nations.
Cost
As it is open source, the license is free. Obviously there are large costs relating to localization, hardware, training, and implementation. I have found one reference to implementation of VISTA over 8 hospitals in one state costing $9 million, as compared to a commercial installation over the same number of hospitals costing $90 million.
Sunset, Discovery Park, Seattle
Sunday, March 20, 2011
Suicide
A very moving post by Anna Roth on her blog about the suicide of her brother in law. She has previously written about suicide, but not this powerfully. The statistics are terrifying, one of the most common causes of death in the 25-44 year old age group, worldwide! Incidence has increased worldwide by 60% over the last few decades. Most common methods are hanging, ingestion, (usually herbicides) and gun shots.
It is estimated that there are 30,000 suicides annually in the US. The most recent data I have seen for Ireland suggest that there are almost 600 reported deaths by suicide annually, a rate substantially higher than the US. The WHO report that the rate in Ireland (11.6 deaths/ 100,000 inhabitants) was 10-15% greater than the average rate in the EU-27.
Can anything be done, an especially pertinent question given our economic collapse and the likely toll that this will cause? While the HSE has a suicide office and a prevention strategy, I have no expertise with which to judge its efficacy. However there are healthcare delivery systems that have shown what can be achieved. The Henry Ford system in Detroit shows what can be achieved. In the first 4 years of the groups suicide prevention program, the rate decreased from 89 to 22 deaths/ 100,000 population. In the most recent analysis the rate over the previous two years had dropped further to zero deaths!
For details, click here. This in a city that has been battered economically over the last decade.
There is another very emotional piece in this weeks JAMA, again an account of suicide from the perspective of a family member. In a future piece, I hope to write about the risks of suicide amongst physicians and ways to reduce this risk.
It is estimated that there are 30,000 suicides annually in the US. The most recent data I have seen for Ireland suggest that there are almost 600 reported deaths by suicide annually, a rate substantially higher than the US. The WHO report that the rate in Ireland (11.6 deaths/ 100,000 inhabitants) was 10-15% greater than the average rate in the EU-27.
Can anything be done, an especially pertinent question given our economic collapse and the likely toll that this will cause? While the HSE has a suicide office and a prevention strategy, I have no expertise with which to judge its efficacy. However there are healthcare delivery systems that have shown what can be achieved. The Henry Ford system in Detroit shows what can be achieved. In the first 4 years of the groups suicide prevention program, the rate decreased from 89 to 22 deaths/ 100,000 population. In the most recent analysis the rate over the previous two years had dropped further to zero deaths!
For details, click here. This in a city that has been battered economically over the last decade.
There is another very emotional piece in this weeks JAMA, again an account of suicide from the perspective of a family member. In a future piece, I hope to write about the risks of suicide amongst physicians and ways to reduce this risk.
Friday, March 18, 2011
Optimizing Patient Flow to enhance productivity and safety, Part 2
Coincidentally, following on from my recent post about patient flow, (March 16th) comes a paper which again demonstrates the critical need to optimize patient flow, not just to improve productivity, but more importantly, to reduce mortality.
Just published this week is a very important paper in the NEJM, here. The authors looked at the effect of nurse staffing numbers on in-hospital mortality in a large academic hospital. It shows that peaks in patient flow (turnovers) are an even greater cause of mortality than patient per nurse staffing ratio. The authors state,
"We also found that the risk of death among patients increased with increasing exposure to shifts with high turnover of patients. Staffing projection models rarely account for the effect on workload of admissions, discharges, and transfers. Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover. In light of the potential importance of turnover on patient outcomes, research is needed to improve the management of turnover and institute workflows that mitigate the effect of this fluctuation."
The basis of this is simple. Elective admissions are hugely variable, and dependent almost entirely on doctor choice. Because these admissions occur without any reference to the other needs of the hospital, they cause huge peaks and troughs in patient numbers, e.g. not many elective patient will be admitted Friday.
One of the worlds leading experts in patient safety, Peter Pronovost, has also made clear his view that optimizing patient flow is essential for reducing in hospital mortality, see this recent paper.
There are huge opportunities to be had.
Just published this week is a very important paper in the NEJM, here. The authors looked at the effect of nurse staffing numbers on in-hospital mortality in a large academic hospital. It shows that peaks in patient flow (turnovers) are an even greater cause of mortality than patient per nurse staffing ratio. The authors state,
"We also found that the risk of death among patients increased with increasing exposure to shifts with high turnover of patients. Staffing projection models rarely account for the effect on workload of admissions, discharges, and transfers. Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover. In light of the potential importance of turnover on patient outcomes, research is needed to improve the management of turnover and institute workflows that mitigate the effect of this fluctuation."
The basis of this is simple. Elective admissions are hugely variable, and dependent almost entirely on doctor choice. Because these admissions occur without any reference to the other needs of the hospital, they cause huge peaks and troughs in patient numbers, e.g. not many elective patient will be admitted Friday.
One of the worlds leading experts in patient safety, Peter Pronovost, has also made clear his view that optimizing patient flow is essential for reducing in hospital mortality, see this recent paper.
There are huge opportunities to be had.
St Patricks Day Parade in Dublin
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