Waste and overuse

I read this paper recently and then reread it (subscription probably required); this I think is destined to become a classic. It touches on subject matter to which I have alluded in recent posts, Quality is goodness, Choosing Wisely and Waste and healthcare costs. The authors set out to examine the extent to which overuse of healthcare resources, defined as inappropriate diagnostics, treatments and medications has been studied. The results were striking in a very negative sense. Medline was searched for a period of 21 years, and a total of 172 papers were found which examined some aspect of overuse:

"We identified 172 articles measuring overuse: 53 concerned therapeutic procedures; 38, diagnostic tests; and 81, medications. Eighteen unique therapeutic procedures and 24 diagnostic services were evaluated, including 10 preventive diagnostic services. The most commonly studied services were antibiotics for upper respiratory tract infections (59 studies), coronary angiography (17 studies), carotid endarterectomy (13 studies), and coronary artery bypass grafting (10 studies)" 

In other words, 172 papers have sought to determine the extent of waste attributable to overuse (in the US healthcare system) out of >114,000 evaluated. Just to re-emphasise, some authorities estimate that waste contributes to 20-30% of US healthcare expenditure and we appear not to have even begun to systematically examine the extent of the problem. Even where the work has been done, it appears the papers are limited to a few main areas, including angiography, CABG, cartotid endartectomy, antibiotics for respiratory infections etc. Not that it is an easy thing to study, but surely government funding agencies should be in these challenging times insisting that more efforts be put into studying these areas rather than focussing on the next addition to our medical arsenal.

Quality is goodness

In the spirit of stealing shamelessly, I am going to plunder Anna Roths latest post from her blog. She summarises a talk by Dr. Don Berwick. Highlights include:

"Quality is Goodness"

"What do we need to do? This is the 2.6 trillion dollar question isn't it? Here is a list to help guide us.

1. Put patients first

2. Protect the disadvantaged 

3. Start at scale –move fast – go "all in"

4. Return the money

5. Act locally"

"The Ethics of Improvement

1. Professionals have a duty to help improve the systems in which they work.
2. Leaders have a duty to make 1. Logistical, feasible and supported.
3. No excuses for inaction on 1 and 2 are acceptable.
4. The duty to improve encompasses safety, efficiency, patient-centeredness, timeliness, effectiveness, and equity requires continual reduction of waste. The IOM six dimensions quality of are dimensions of goodness
5. Those who educate professionals have the duty to prepare them for improvement work."

Wow, in 25 plus years of training, working, and teaching, no-one has ever said to me there is an ethical duty to educate professionals for improvement. Self evident but an indication of why we are finding healthcare improvement to be so challenging. 

Anna is always worth reading. Follow her blog and twitter. 

First contact with Deming

According to Charles Kenney in his book, "The Best Practice" Dr. Paul Batalden first became aware of Deming and his work when he read an article about him in the New York Times. As far as I can ascertain, the article is here, well worth a read. From Batalden, it appears the Deming gospel was spread to Dr. Berwick. From small acorns, great oaks grow. By the way, The Best practice is well worth a read for all you healthcare quality junkies out there.

Waste and healthcare costs

Dr Berwick has written two pieces in which he makes the case that waste broadly defined accounts for 20-30% of US healthcare expenditure. JAMA article requires subscription here and Boston Globe piece here.

He defines waste as follows:

1. Over-treatment
2. Failures of care coordination
3. Failures in execution of care processes
4. Administrative complexity
5. Pricing failures, and 
6. Fraud and abuse

I can certainly see items 1-5 occurring in our system; whether fraud contributes a substantial amount, I just dont have the data. I am guessing failed IT implementation falls into category 4. Interestingly the Vanguard organisation has provided initial estimates based on preliminary work that what they term failure demand (which would certainly fit into category 1-4 above accounts for a very substantial proportion of healthcare activity), for an example see here.