15 More Medical Procedures To Avoid
The Mayo Clinic's review of ten year's worth of medical reversals published by a leading journal turned up a host of medical procedures that were once thought to be the standard of care. The latest evidence says that they are not worth the risk or the cost.
1) Anticonvulsant drugs during pregnancy
In 2001 a large observational study confirmed suspicions that anticonvulsants taken in pregnancy increase the risk of fetal abnormality.
2) Chelation therapy to prevent cognitive impairment in children with moderately elevated lead levels
Using chelation therapy with succimer did reduce neuropsychological delays in a randomized, placebo-controlled trial of children with moderately high blood lead levels.
3) Treatment of asymptomatic Trichomonas vaginalis during pregnancy
A randomized trial found that using metronidazole did not prevent preterm delivery in women with asymptomatic Trichomonas vaginalis.
4) Estrogen plus progestin hormone therapy to reduce heart disease or coronary artery disease
Postmenopausal women were randomized and given either estrogen/progesterone or a placebo. After 5 years the hormone replacement therapy had provided no protection against cardiac disease. In a second study postmenopausal hormone therapy did not provide protection against coronary-artery artherosclerosis either.
5) Nebulized epinephrine for infants with acute bronchiolitis
Even though epinephrine tratmentfor infants provides short-term improvement in bronchiolitis symptoms, a randomized, double blind study found that it did not shorten the overall time spent in the hospital.
6) Corticosteroids for bronchiolitis in children
Oral dexamethasone, given as a single dose in the emergency room, did not improve outcomes or reduce hospitalizations for children in a randomized and controlled study.
7) Lung transplant for cystic fibrosis
A large retrospective study found that lung transplants cannot be expected to extend life or improve quality of life for end-stage cystic fibrosis patients.
8) Corticosteroids for preschool children with wheezing due to upper respiratory infections
Virus-induced wheezing was not reduced in children who were treated with prednisolone in a large, randomized and double-blind trial.
9) Acyclovir for Bell's Palsy
A randomized, controlled study found that acyclovir, either alone or as an adjunct therapy, did not benefit patients.
10) Saw Palmetto for prostate enlargement
A year-long double-blind trial of 225 middle-aged men found they had no improvement after using saw palmetto (160 mg twice per day) for the treatment of benign prostatic hyperplasia.
11) Antidepressants as an adjunct in bipolar disorder
Adding standard antidepressants to a patient's regimen neither was not found to increase mood polarity but it didn't decrease it either.
12) Irradiation for breast cancer in women over 70
For women over 70 who have a lumpectomy with Tamoxifen for the treatment of estrogen receptor positive breast cancer the addition of irradiation was not better than lumpectomy with Tamoxifen alone in a randomized study.
13) Stents instead of artery bypass for multivessel coronary bypass disease
A large observational study in New York State found that stenting did not work better than traditional coronary-artery bypass for patients with disease in mulitiple vessels.
14) Vertebroplasty for fractured spinal bone
Despite being paid for by Medicare and performed on over 27,000 patients in 2004, vertebroplasty (the injection of cement into the bone) produced no better results than a sham procedure.
15) Delay of epidural anesthesia for women in labor
A 2005 study found that using systemic opioids in early labor gave did not reduce C-section rates compared to epidurals.
Thursday, September 19, 2013
Friday, August 30, 2013
10 Medical Practices that Aren’t Worth the Money
There are plenty of media reports about exciting advances in medicine. But those same outlets seem to go silent when what had initially appeared to be a breakthrough fails the next round of studies. It happens surprisingly often. This becomes a problem when practioners don't keep up with current research. They may continue to use older treatments or procedures, even after those interventions have been shown to be ineffective or even harmful. The Mayo Foundation for Medical Education and Research recently set out to address this problem. Their team, led by Dr. Vinay Prasad, looked at ten years of research articles published in a top journal to examine how many of the treatments, procedures, tests, surgeries, screenings, medications or other interventions in use today have truly been shown to work. Only 38% of articles evaluating established treatments found them to be beneficial. More than 40% of the published studies looking at an established treatment found it to be no better than or worse than the standard practice. To be clear, this doesn’t mean that 40% of procedures were ineffective. It means that in 40% of the studies reviewed, earlier positive results were superseded by later studies that reversed initial findings. To disprove earlier work a new study had to be more rigorously designed, better powered or better controlled.
1) Prolonged antibiotic treatment for persistent symptoms of Lyme disease. A 90-day course of antibiotics didn’t lead to patient improvement in a randomized, placebo-controlled trial.
2) The use of mite-allergen impermeable mattress pads and pillow covers to prevent asthma in adults. A double-blind, placebo-controlled and randomized study done in 2003 found this type of bedding had no impact on asthma symptoms.
3) Aggressive control of blood sugar to prevent heart disease. A large 2008 study found that intensive glucose lowering in diabetics actually increased mortality and did not prevent cardiac problems. Adhering to more permissive glucose targets gave patients better outcomes.
4) Naltrexone to treat alcoholism. A multi-center, randomized and placebo-controlled study failed to find that naltrexone, an opioid-receptor antagonist, added any benefit to standard psychosocial treatment.
5) Antibiotics for asymptomatic UTIs in diabetic women. In 2002 a randomized trial found that antibiotics did not reduce diabetic women’s time to symptomatic infection, or the number of complications due to urinary tract infections.
6) Arthroscopic surgery for osteoarthritis of the knee. Two controlled studies failed to find benefit from this procedure.
7) Hypothermia during aneurysm surgery. The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) found in 2005 that cooling patients during neurosurgery for aneurysm provided no post-operative neurologic benefit.
8) High-dose chemotherapy with autologous stem-cell transplants for high-risk breast cancer. Even though this procedure reduced cancer relapse rates in the affected breast/axillary area , a randomized trial failed to find that it increased survival rates compared to conventional adjuvant chemotherapy.
9) Preimplantation genetic screening for IVF. Genetic screening during in vitro fertilization for women of advanced maternal age was studied in a multicenter, double-blind study. The researchers concluded that preimplantation genetic screening actually reduced the number of pregnancies and live births.
10) Inserting stents in patients with coronary artery infarction. In a randomized trial of people who had suffered total blockage of an artery (myocardial infarction), patients were randomly assigned to a group who received either optimal medical therapy or optimal medical therapy with stents. The stented group did no better in terms of survival rate, reinfarction or heart failure.
Read the Study: A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices
By Vinay Prasad,MD; Andrae Vandross, MD; Caitlin Toomey, MD; Michael Cheung, MD; Fason Rho, MD; Steven Quinn,MD; Jacob Chacko, MD; Durga Bonkar, MD; Victor Gall, MD; Senthil Selvaraj, MD; Nancy Ho, MD; and Adam Cifu, MD
There are plenty of media reports about exciting advances in medicine. But those same outlets seem to go silent when what had initially appeared to be a breakthrough fails the next round of studies. It happens surprisingly often. This becomes a problem when practioners don't keep up with current research. They may continue to use older treatments or procedures, even after those interventions have been shown to be ineffective or even harmful. The Mayo Foundation for Medical Education and Research recently set out to address this problem. Their team, led by Dr. Vinay Prasad, looked at ten years of research articles published in a top journal to examine how many of the treatments, procedures, tests, surgeries, screenings, medications or other interventions in use today have truly been shown to work. Only 38% of articles evaluating established treatments found them to be beneficial. More than 40% of the published studies looking at an established treatment found it to be no better than or worse than the standard practice. To be clear, this doesn’t mean that 40% of procedures were ineffective. It means that in 40% of the studies reviewed, earlier positive results were superseded by later studies that reversed initial findings. To disprove earlier work a new study had to be more rigorously designed, better powered or better controlled.
Here are some of the practices that didn't pass that second look:
2) The use of mite-allergen impermeable mattress pads and pillow covers to prevent asthma in adults. A double-blind, placebo-controlled and randomized study done in 2003 found this type of bedding had no impact on asthma symptoms.
3) Aggressive control of blood sugar to prevent heart disease. A large 2008 study found that intensive glucose lowering in diabetics actually increased mortality and did not prevent cardiac problems. Adhering to more permissive glucose targets gave patients better outcomes.
4) Naltrexone to treat alcoholism. A multi-center, randomized and placebo-controlled study failed to find that naltrexone, an opioid-receptor antagonist, added any benefit to standard psychosocial treatment.
5) Antibiotics for asymptomatic UTIs in diabetic women. In 2002 a randomized trial found that antibiotics did not reduce diabetic women’s time to symptomatic infection, or the number of complications due to urinary tract infections.
6) Arthroscopic surgery for osteoarthritis of the knee. Two controlled studies failed to find benefit from this procedure.
7) Hypothermia during aneurysm surgery. The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) found in 2005 that cooling patients during neurosurgery for aneurysm provided no post-operative neurologic benefit.
8) High-dose chemotherapy with autologous stem-cell transplants for high-risk breast cancer. Even though this procedure reduced cancer relapse rates in the affected breast/axillary area , a randomized trial failed to find that it increased survival rates compared to conventional adjuvant chemotherapy.
9) Preimplantation genetic screening for IVF. Genetic screening during in vitro fertilization for women of advanced maternal age was studied in a multicenter, double-blind study. The researchers concluded that preimplantation genetic screening actually reduced the number of pregnancies and live births.
10) Inserting stents in patients with coronary artery infarction. In a randomized trial of people who had suffered total blockage of an artery (myocardial infarction), patients were randomly assigned to a group who received either optimal medical therapy or optimal medical therapy with stents. The stented group did no better in terms of survival rate, reinfarction or heart failure.
Read the Study: A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices
By Vinay Prasad,MD; Andrae Vandross, MD; Caitlin Toomey, MD; Michael Cheung, MD; Fason Rho, MD; Steven Quinn,MD; Jacob Chacko, MD; Durga Bonkar, MD; Victor Gall, MD; Senthil Selvaraj, MD; Nancy Ho, MD; and Adam Cifu, MD
Friday, August 9, 2013
How High Performance Organizations Get the Most Out of Training
Best Practices from the Science of Training
Training works, if it is well designed. Researchers have been studying training
methods for 40 years now, and they've got robust evidence to show that done
right, training boosts organizational effectiveness. NASA and the US Navy
recently sponsored a study to find out what cognitive science, engineering, and
industrial psychology have taught us in the last few decades. The project’s
lead author, Eduardo Salas at the University of Central Florida, found that
it’s crucial for training systems to be properly integrated into the organization. His report identifies the keys to spending
training dollars wisely.
1. It may seem
obvious, but the first thing to consider is whether you really need training at
all. Decide if the issue is actually structural or organizational. If it is,
don’t waste time and money throwing training at problems it won’t fix.
2. Do a needs
assessment. What are organizational
needs, and then what skills, knowledge or competencies are required to fulfill
those needs? Make sure that the training
program is tailored to these needs.
There are lots of fads and glitzy technological delivery systems out
there but only use training programs that have measurable effects on job
performance.
3. Do a personnel assessment. Identify which employees have the greatest
gap between competencies and
requirements and focus on those employees. Don’t train everybody unless there is a specific reason to.
4. Make sure the training is suited to the needs of those
whose skills need upgrading. Older
workers, for example, may require a slower pace to master new technologies.
5. Teach supervisors
how to focus on training’s benefits and make sure it is regarded positively
within the organization. Introduce training as
an opportunity to advance the employee’s career, not as a test or an indictment
of his or her incompetence. On the other hand, don’t oversell it. Unrealistic expectations lower performance.
6. Maximize learning
by not overloading trainees with too much content. Focus on what is crucial to know and how to
access the rest.
7. Teach error
tolerance. Build in difficulties and
challenges so that trainees have the opportunity to fail. Good training teaches emotional as well as
cognitive skills. Employees need to
become comfortable with detecting and correcting their own errors.
8. Model proficiency and competence with the new material or
skill, and make sure the training includes practice and feed-back.
9. Create ongoing
learning by debriefing afterwards and linking trainees into communities of
practice.
10. Minimize skill
decay by scheduling training as close to its application as possible.
Wednesday, July 24, 2013
Simple Tools to Help People Navigate the ACA
As the government rolls out the Affordable Care Act a lot of people are going to want to know how they will be affected and what, if anything, they should sign up for. They will need to make decisions regarding the level of care they can afford and the benefits that they need. The non-profit Kaiser Family Foundation has decided to make the process as painless as possible by creating a simple introductory video. It provides an overview of the Act's provisions and explains the different ways people will be getting coverage. To create an estimate of their costs the video also links to a subsidy calculator.
The calculator estimates what individuals who purchase their own insurance through the new exchanges will get. It asks users to input age, income and number of dependents. For example, a 21-year old making $20,000 a year can enroll in the silver plan for about $85 a month or the bronze plan for about $42 a month.
In order to keep costs down it is particularly important that young people aged 18-35 sign up. Sarah Kliff over at the Washington Post's Wonk Blog has been keeping us up to date on the White House's efforts to roll out the program smoothly. If you want more information about where they are concentrating their efforts and the target demographics they are trying to reach see her recent post.
The calculator estimates what individuals who purchase their own insurance through the new exchanges will get. It asks users to input age, income and number of dependents. For example, a 21-year old making $20,000 a year can enroll in the silver plan for about $85 a month or the bronze plan for about $42 a month.
In order to keep costs down it is particularly important that young people aged 18-35 sign up. Sarah Kliff over at the Washington Post's Wonk Blog has been keeping us up to date on the White House's efforts to roll out the program smoothly. If you want more information about where they are concentrating their efforts and the target demographics they are trying to reach see her recent post.
Wednesday, July 17, 2013
Thyroid Cancer "Epidemic" Likely Due to Overdiagnosis
Detection Rates Continue to Rise But Thyroid Cancer Deaths Stay the Same
The Takeaway
1. The number of papillary thyroid cancer cases treated has been going up in the US, Canada and Western Europe. In 2009 the incidence was three times what it had been in 1973, rising from 3.5 cases per 100,000 people to 12.5 cases per 100,000.
2. In a study published July 8th in the journal Thyroid, a team led by Luc Morris, MD MSc at Memorial Sloan-Kettering Cancer Center found a positive correlation between indicators of healthcare use and thyroid cancer diagnosis in the US. This looks like good news but it's actually a problem. The poor and those without access to care are getting fewer thyroid cancer diagnoses than those with access, even though both succumb to the disease at the same rate.
2. In a study published July 8th in the journal Thyroid, a team led by Luc Morris, MD MSc at Memorial Sloan-Kettering Cancer Center found a positive correlation between indicators of healthcare use and thyroid cancer diagnosis in the US. This looks like good news but it's actually a problem. The poor and those without access to care are getting fewer thyroid cancer diagnoses than those with access, even though both succumb to the disease at the same rate.
3. If more cases of a fatal disease are diagnosed and treated, but death rates don't decrease, the new cases being detected are likely part of a subclinical disease reservoir. These are cases that would not have gone on to cause harm if left alone. Treating subclinical cases is not only unnecessary, it is also harmful and costly. This is what is meant by the term overdiagnosis.
4. The authors speculate that the increase is due to the use of sensitive diagnostic tools such as ultrasonography, fine needle aspiration biopsy and the fact that small nodules sometimes show up "incidentally" when radiographic imaging is done for other reasons.
5. Census 2000 data was used to look at 9 socioeconomic variables across 443 US counties. SEER data provided patient demographic information, tumor and survival characteristics. An ecologic analysis and regression analysis were performed. Counties with higher income and education levels had more thyroid cancer cases than counties with more unemployment, non-English speakers, and poverty.
The One Minute Summary
Overdiagnosis is thought to occur when a reservoir of previously undetected, and non-lethal disease is revealed by new, more sensitive technologies. Papillary thyroid cancer fits this description because autopsies have revealed that between 8 and 35% percent of us are likely to go to our graves with detectable thyroid tumors, even if we have died from other causes. This latest study adds new evidence to the case for concluding that the rise in thyroid cancers over the last three decades is due to changes in the techniques of detection, rather than some change in the environment. It found that where there are more poor, non-English speaking, or unemployed adults, there is a lower rate of thyroid cancer diagnosis. And, crucially, that lower rate of diagnosis doesn't change life expectancy.
Read the Study: The Increasing Incidence of Thyroid Cancer: The Influence of Access to Care
By Luc Morris, MD MSc; Andrew Sikora, MD PhD; Tor Tosteson, ScD; and Louis Davis, MD MS
5. Census 2000 data was used to look at 9 socioeconomic variables across 443 US counties. SEER data provided patient demographic information, tumor and survival characteristics. An ecologic analysis and regression analysis were performed. Counties with higher income and education levels had more thyroid cancer cases than counties with more unemployment, non-English speakers, and poverty.
The One Minute Summary
Overdiagnosis is thought to occur when a reservoir of previously undetected, and non-lethal disease is revealed by new, more sensitive technologies. Papillary thyroid cancer fits this description because autopsies have revealed that between 8 and 35% percent of us are likely to go to our graves with detectable thyroid tumors, even if we have died from other causes. This latest study adds new evidence to the case for concluding that the rise in thyroid cancers over the last three decades is due to changes in the techniques of detection, rather than some change in the environment. It found that where there are more poor, non-English speaking, or unemployed adults, there is a lower rate of thyroid cancer diagnosis. And, crucially, that lower rate of diagnosis doesn't change life expectancy.
Read the Study: The Increasing Incidence of Thyroid Cancer: The Influence of Access to Care
By Luc Morris, MD MSc; Andrew Sikora, MD PhD; Tor Tosteson, ScD; and Louis Davis, MD MS
Wednesday, June 19, 2013
Study Finds That New Drugs Don't Look So Good Now that All Clinical Trials Must Be Registered
The FDA has traditionally required drug manufacturers to show that their products are more effective than a placebo, and that they don't do harm. But that is a low bar to jump. What patients and medical professionals really need to know is whether a new drug is better than the ones currently in use. Comparative effectiveness research is designed to answer this, and more specific questions. Does a new drug have fewer side effects, work in different care settings, work better for certain groups of patients, or in some other way prove its mettle?
This month Mark Olfson and Steven C. Marcus published a study in Health Affairs using the statistical tools of effectiveness research to take a new look at old drug studies, those reported in major medical journals from 1966 to 2010. A random sample of studies found that over time the effect size of new drugs has decreased. The newer the drug, the less effective it tends to be. We are getting diminishing returns for our health care buck.
The authors discussed several reasons this could be happening. New drugs are still coming to market, but there have been relatively few new drug classes. This is especially true of antibiotics. A second issue is that with the requirement in the U.S. since 2007 that all clinical trials be registered, there is no longer the opportunity to select only the strongest studies for publication. This would imply that the effectiveness of our medications was being statistically pumped up before the ClinicalTrials.gov registry was formed. A third possibility is that drug manufacturers have preferred to bring variations of already popular drugs to market rather than investing the time and money to develop new ones. In order to get the new version to pass FDA review they may resort to increasing the number of participants in the trial. Even a very small effect size can look statistically significant against a placebo with a large enough sample size. Sample sizes have indeed increased over the study period, making it a real possibility that drugs offering only a small tweak from standard treatments can pass review.
As the authors note, $100 billion is spent in the U.S. on biomedical research every year, and most of that is going into clinical trials. The diminishing rate of returns that this money has had in terms of clinical effectiveness makes it imperative that we shine light on this process. We need to guard against having clinical trials being used as marketing tools, and put the focus back on the reduction of human harm and suffering.
Read the Study: Decline in Placebo-Controlled Trial Results Suggests New Directions For Comparative Effectiveness Research
By Mark Olfson and Steven C. Marcus
As the authors note, $100 billion is spent in the U.S. on biomedical research every year, and most of that is going into clinical trials. The diminishing rate of returns that this money has had in terms of clinical effectiveness makes it imperative that we shine light on this process. We need to guard against having clinical trials being used as marketing tools, and put the focus back on the reduction of human harm and suffering.
Read the Study: Decline in Placebo-Controlled Trial Results Suggests New Directions For Comparative Effectiveness Research
By Mark Olfson and Steven C. Marcus
Monday, June 3, 2013
The Affordable Care Act's Surprisingly Low Premiums
As implementation of the Affordable Care Act ramps, up two unexpected developments have been in the news. Some health plans look to be offered at a cost well below that predicted. This is good news and bad news.
The good news is that California's Insurance Exchange, called Covered California, has released its prices. It will be offering plans for 2014 at an unexpectedly low cost. This is because the Exchanges, which were designed to create a competitive marketplace for health insurance are actually functioning like a competitive marketplace. Consumers can choose between four levels of plan: bronze, silver, gold or platinum. The more the plan costs up front, the lower the out-of pocket expenses will be. All the insurance companies offering bronze plans have to include the same types of services for those plans. All the silver plans have to be comparable to each other, and so on. Now that plans can actually be rated in a simple and transparent way, there is an incentive for insurers to bid low and compete against each other to gain market share.
Covered California is offering low rates despite expectations that premiums under Obamacare were going to rise. A widely reported study by the Milliman Company predicted that while older Americans aged 40-59 should see lowered costs, younger males would see their cost go up. A 28-year-old man making $50,000 a year, for example, had been expected to pay as much as $450 a month for a silver plan. The actual cost in California is going to be around $250 a month. This is comparable in cost to high-deductible plans on the private insurance market right now which offer much-less comprehensive benefits. All plans purchased through Insurance Exchanges must cover at least 60% of the patient's costs, including co-pays and deductibles. California residents who buy through Covered California are going to get a good deal.
The same can't be said for all low-wage workers at large companies. Christopher Weaver and Anna Wilde Matthews at the Wall Street Journal recently reported that some companies with large numbers of service workers have been worried about the cost of the ACA's requirement to offer those employees health benefits. They are said to be in talks with insurance companies to craft new plans that will be very cheap, in the order of $40 a month, but will offer extremely limited coverage. Hospital stays, surgery and prenatal care will be excluded.
These firms are hoping to find a loop-hole in the law that allows them to offer low-benefit plans (termed mini-meds or "skinny plans" in insurance industry lingo). Since most large firms offering insurance to their employees actually offer good plans in order to retain workers (think Google), big companies have been allowed to choose their own plans. The Department of Health and Human Services didn't anticipate that offering skinny plans might be the way that some companies would try to lower premium costs. It is unlikely that they will be allowed to, but watch this space for further developments.
The good news is that California's Insurance Exchange, called Covered California, has released its prices. It will be offering plans for 2014 at an unexpectedly low cost. This is because the Exchanges, which were designed to create a competitive marketplace for health insurance are actually functioning like a competitive marketplace. Consumers can choose between four levels of plan: bronze, silver, gold or platinum. The more the plan costs up front, the lower the out-of pocket expenses will be. All the insurance companies offering bronze plans have to include the same types of services for those plans. All the silver plans have to be comparable to each other, and so on. Now that plans can actually be rated in a simple and transparent way, there is an incentive for insurers to bid low and compete against each other to gain market share.
Covered California is offering low rates despite expectations that premiums under Obamacare were going to rise. A widely reported study by the Milliman Company predicted that while older Americans aged 40-59 should see lowered costs, younger males would see their cost go up. A 28-year-old man making $50,000 a year, for example, had been expected to pay as much as $450 a month for a silver plan. The actual cost in California is going to be around $250 a month. This is comparable in cost to high-deductible plans on the private insurance market right now which offer much-less comprehensive benefits. All plans purchased through Insurance Exchanges must cover at least 60% of the patient's costs, including co-pays and deductibles. California residents who buy through Covered California are going to get a good deal.
The same can't be said for all low-wage workers at large companies. Christopher Weaver and Anna Wilde Matthews at the Wall Street Journal recently reported that some companies with large numbers of service workers have been worried about the cost of the ACA's requirement to offer those employees health benefits. They are said to be in talks with insurance companies to craft new plans that will be very cheap, in the order of $40 a month, but will offer extremely limited coverage. Hospital stays, surgery and prenatal care will be excluded.
These firms are hoping to find a loop-hole in the law that allows them to offer low-benefit plans (termed mini-meds or "skinny plans" in insurance industry lingo). Since most large firms offering insurance to their employees actually offer good plans in order to retain workers (think Google), big companies have been allowed to choose their own plans. The Department of Health and Human Services didn't anticipate that offering skinny plans might be the way that some companies would try to lower premium costs. It is unlikely that they will be allowed to, but watch this space for further developments.
Wednesday, May 22, 2013
Tutorial Part II : The Affordable Care Act and Small Businesses
If Your Business Employs Fewer Than 50 People You Are Exempt From Having to Offer Health Coverage
The Takeaway
1) Small businesses receive preferential treatment under the Affordable Care Act. If they have fewer than 50 employees they don't have to provide their employees health insurance.
2) For small business owners wanting to offer their employees coverage, the states' new Insurance Exchanges will make it easier. Exchanges have been designed to simplify comparison of rates and services.
4) Really small businesses, those with fewer than 10 employees, whose full-time workers average $25,000 or less, can get a 100% tax credit on their contribution to employee coverage.
5) Next year the tax credit goes up. For-profit companies will be able to claim up to a 50 % tax credit on plans offered through the Exchanges.
The One Minute Summary
There has been a lot of talk in the media about the impact of the ACA on small businesses, but the overall effect looks to be positive. The Act will help keep workers healthy and the coverage is subsidized. To qualify for tax credits businesses need to obtain their health plans through the Exchanges. Most large companies already offer insurance so little will change for them. Companies who are worried about the effects of the ACA tend to be large and to have many low-wage workers. They are going to be required to offer full-time employees (over 29 hours) insurance or face fines.
Go to the Source: Health Insurance 101
By Community Catalyst & Georgetown University Health Policy Institute
The Takeaway
1) Small businesses receive preferential treatment under the Affordable Care Act. If they have fewer than 50 employees they don't have to provide their employees health insurance.
2) For small business owners wanting to offer their employees coverage, the states' new Insurance Exchanges will make it easier. Exchanges have been designed to simplify comparison of rates and services.
3) A lot of small businesses will get tax credits for covering their employees. They have to have fewer than 25 workers making an average of $50,000 or less, contribute at least half of the cost of the plan, and use the Insurance Exchanges. If they meet these criteria, non-profits will receive a 25% credit this year. For-profit businesses will do even better. They can claim a 35% tax credit for their part of the premium.
4) Really small businesses, those with fewer than 10 employees, whose full-time workers average $25,000 or less, can get a 100% tax credit on their contribution to employee coverage.
5) Next year the tax credit goes up. For-profit companies will be able to claim up to a 50 % tax credit on plans offered through the Exchanges.
The One Minute Summary
There has been a lot of talk in the media about the impact of the ACA on small businesses, but the overall effect looks to be positive. The Act will help keep workers healthy and the coverage is subsidized. To qualify for tax credits businesses need to obtain their health plans through the Exchanges. Most large companies already offer insurance so little will change for them. Companies who are worried about the effects of the ACA tend to be large and to have many low-wage workers. They are going to be required to offer full-time employees (over 29 hours) insurance or face fines.
Go to the Source: Health Insurance 101
By Community Catalyst & Georgetown University Health Policy Institute
Saturday, May 18, 2013
US Spends More Than Any Other Nation On Healthcare But Is Outranked On Life Expenctancy
 |
| Source: Gapminder.com |
US citizens have a lower life expectancy at birth than citizens born in any European country, despite having the highest rate of health care spending.
You probably already knew this. But did you know that you can now present this information in a visual form that is colorful, simple to grasp and interactive? Credit the nonprofit organization, Gapminder, created by Hans Rosling. It created a site with the map above and lots of others on global health and development. They are free to use and the site includes tutorials that make them easy to work with, even for novices. Educators will particularly appreciate the section on how to integrate the map projects and activities into the classroom.
Friday, May 10, 2013
Tutorial: A Quick and Dirty Guide to the Affordable Care Act (Obamacare)
Part 1: Seven Ways the ACA Is Expected to Reduce the Federal Deficit
The Takeaway
The Congressional Office of Management and Budget (OMB) projects that Obamacare will shave $140 billion off the federal deficit in its first decade, and over one trillion dollars in the decade after that. There are no drastic cuts, instead, a number of incremental cost-savings measures have been put together which are expected to add up over time. Some of the most important ones:
1) A 40% excise tax on high-cost health care plans (so-called Cadillac plans). The idea is to reverse the perverse incentives now in place that encourage over-utilization, and shift consumers to lower-cost plans. High-cost plans will be defined as costing over $10,200 for an individual, or $27,500 for a family, in 2018.
2) An increase in Medicare payroll tax by .9%.
3) New excise taxes on pharmaceutical companies, health insurance companies and medical device makers.
4) A reduction in the inflation adjustments for Medicare payments to hospitals.
5) A reduction in payments to Medicare Advantage (the private alternative to Medicare for seniors).
6) Small businesses (under 100 employees) are actually expected to save money on health insurance and pass on those savings to their employees in the form of higher wages. Those wages would then be taxed, providing the government revenue. [This one sounds optimistic to me.]
There are also number of experimental projects included in the legislation that aim to save money by reducing the amount spent on inefficiencies such as medical mistakes, or treatments that don't provide benefit. These measures include:
The Takeaway
The Congressional Office of Management and Budget (OMB) projects that Obamacare will shave $140 billion off the federal deficit in its first decade, and over one trillion dollars in the decade after that. There are no drastic cuts, instead, a number of incremental cost-savings measures have been put together which are expected to add up over time. Some of the most important ones:
1) A 40% excise tax on high-cost health care plans (so-called Cadillac plans). The idea is to reverse the perverse incentives now in place that encourage over-utilization, and shift consumers to lower-cost plans. High-cost plans will be defined as costing over $10,200 for an individual, or $27,500 for a family, in 2018.
2) An increase in Medicare payroll tax by .9%.
3) New excise taxes on pharmaceutical companies, health insurance companies and medical device makers.
4) A reduction in the inflation adjustments for Medicare payments to hospitals.
5) A reduction in payments to Medicare Advantage (the private alternative to Medicare for seniors).
6) Small businesses (under 100 employees) are actually expected to save money on health insurance and pass on those savings to their employees in the form of higher wages. Those wages would then be taxed, providing the government revenue. [This one sounds optimistic to me.]
- Creation of Accountable Care Organizations (ACOs) designed to improve the efficiency and delivery of care
- Creation of an Independent Advisory Board to oversee Medicare payment reductions in the event that expenditures exceed guidelines
- Replacing fee-for-service payments with bundled payments
- Creation of the Patient-Centered Outcomes Research Institute to study comparative effectiveness of medicines, tests and procedures
Read the reports: Impacts of the Affordable Care Act: How Reasonable are the Projections? (free)
by Jonathan Gruber for the New England Center for Economic Research
Despite Criticism, The Affordable Care Act Does Much to Contain Health Care Costs (free)
by Stephen Zuckerman and John Holahan at the Urban Institute
by Stephen Zuckerman and John Holahan at the Urban Institute
Monday, April 29, 2013
Report on How to Reduce Regional Variation in Medicare Spending is Due this Summer
It has been well-documented that regional differences in Medicare spending persist. From 2007 to 2009 Medicare spent 1.43 times more on the average patient in geographic regions at the top 10th cost percentile than it did for patients in the 90th percentile. This was even after controlling for variations in wages and cost of living. Congress has asked the Institute of Medicine (IOM) to convene a committee to look into this issue and make policy recommendations. Dr Joseph Newhouse and Dr. Alan Garber, chair and vice-chair of that committee recently published an article describing their progress in the New England Journal of Medicine. After reviewing the literature, and commissioning studies of their own, they have made some preliminary findings.
The Takeaway
1) Post-acute care, that is skilled nursing facilities, home health aids, rehabilitation facilities, long-term care and hospices accounted for most of the variation in spending. In Miami, Medicare reimbursements for post-acute care are over four times the national average, so far off the scale that it actually suggests fraud.
2) The second type of health service that varied significantly is hospital inpatient services, including physician reimbursements.
3) Spending on all other categories: prescription drugs, emergency care and ambulances, outpatient procedures, diagnostic testing varied only slightly.
4) Comparing spending rates at individual hospital service areas (HSAs) within the larger regional market showed that there was considerable variation among hospitals in the same area.
5) When the committee looked at spending rates for different medical conditions within market areas, it also found little uniformity. Points four and five suggest that it is physician culture within specialties that dictates the aggressiveness of treatment within a region, not patient health status.
6) There was little correlation between regional spending and quality indicators.
The committee's actual policy recommendations will come out this summer. From what they have learned so far, it looks like those recommendations will focus on trying to change individual provider behavior rather than region-wide activity.
TL:DR Medicare is going to have to clamp down on higher-than-average spending in post-acute care facilities and in-patient hospital services if they want to substantially control costs.
Read the article: Geographic Variation in Medicare Services (free)
By Joseph P. Newhouse, Ph.D., and Alan Garber, M.D., Ph.D.
The Takeaway
1) Post-acute care, that is skilled nursing facilities, home health aids, rehabilitation facilities, long-term care and hospices accounted for most of the variation in spending. In Miami, Medicare reimbursements for post-acute care are over four times the national average, so far off the scale that it actually suggests fraud.
2) The second type of health service that varied significantly is hospital inpatient services, including physician reimbursements.
3) Spending on all other categories: prescription drugs, emergency care and ambulances, outpatient procedures, diagnostic testing varied only slightly.
4) Comparing spending rates at individual hospital service areas (HSAs) within the larger regional market showed that there was considerable variation among hospitals in the same area.
5) When the committee looked at spending rates for different medical conditions within market areas, it also found little uniformity. Points four and five suggest that it is physician culture within specialties that dictates the aggressiveness of treatment within a region, not patient health status.
6) There was little correlation between regional spending and quality indicators.
The committee's actual policy recommendations will come out this summer. From what they have learned so far, it looks like those recommendations will focus on trying to change individual provider behavior rather than region-wide activity.
TL:DR Medicare is going to have to clamp down on higher-than-average spending in post-acute care facilities and in-patient hospital services if they want to substantially control costs.
Read the article: Geographic Variation in Medicare Services (free)
By Joseph P. Newhouse, Ph.D., and Alan Garber, M.D., Ph.D.
Tuesday, April 23, 2013
What Behavioral Economics Has to Teach Us About Reining in Health Care Costs
"As the crisis of cost containment becomes ever more pressing we need to explore all possibilities."
The Takeaway
Dominic King, a clinical lecturer at Imperial College London, and coauthors study behavioral change and its application to health care policy. Their recent article, published in Health Affairs last month, recaps a watershed report on behavioral economics originally produced for the UK government. After reviewing the current research and interviewing key scientists and policy makers, they identified nine aspects of human behavior that policy makers should pay attention to in the effort to slow spending.
1) Source Credibility: Physicians have been shown to believe information from their own professional organizations more readily than the same information from insurance companies. Parents have been shown to heed vaccine advice from their child's pediatricians more readily than the same advice from government officials. Send messages from appropriate sources.
2) Incentives: People are "loss averse" and respond better to the fear of loss than the hope of reward. Awareness of this cognitive bias has been successfully applied to medication adherence and weight loss programs.
3) Norms: Peer group norms are powerful influences on behavior but they can be mispercieved. Alcohol consumption, for instance, was reduced in one study when educators communicated the actual norms of college drinking to students. They had believed that their peers were drinking much more than they actually were.
4) Defaults: At Vanderbilt University Medical Center setting an electronic prescription default to a generic drug worked better than traditional educational campaigns to get physicians to prescribe generic drugs.
5) Salience: Having salient cost information available to physicians has been shown to decrease the costs of the tests they prescribe.
6) Priming: Environmental factors have significant impacts on choices. Studies find, for example, that children exposed to food advertisements consumed 45 percent more calories than those who weren't exposed. Even simple environmental cues like larger plates increase food consumption.
7) Affect: Emotions play an important role in guiding our decisions. Asking patients to make important treatment decisions too soon after hearing bad news risks putting them at risk for a response based on transient fear, anxiety, and/or pain, rather a full assessment of the benefits and consequences.
8) Commitments: Self-commitment devices such as pre-paid gym memberships help people boost their willpower. Smoking cessation programs have used this technique with success by having quitters put money into a savings account which is only returned to them if they pass a nicotine-detecting urine test after six months.
9) Ego: Status among our peers is important to us. Hospitals that do better a providing high-quality, cost-effective services should have their performance publicized and recognized.
The One Minute Summary
Behavioral economics goes beyond the traditional assumption that we are all rational creatures who reliably make choices in our own best interests. Drawing on psychological research, it looks at the full set of drivers affecting our behavior. Often these are unconscious emotions, biases, preconceptions and tendencies. These ideas have already begun to be applied to patient safety efforts, but they could be more widely employed. The authors point out that ethical considerations, making sure that these levers are used to enhance people's critical choice-making rather than reduce it, are crucially important.
Read the Study: Approaches Based On Behavioral Economics Could Help Nudge Patients And Providers Toward Lower Health Spending Growth
By: Dominic King, Felix Greaves, Ivo Vlaev and Ara Darzi
The Takeaway
Dominic King, a clinical lecturer at Imperial College London, and coauthors study behavioral change and its application to health care policy. Their recent article, published in Health Affairs last month, recaps a watershed report on behavioral economics originally produced for the UK government. After reviewing the current research and interviewing key scientists and policy makers, they identified nine aspects of human behavior that policy makers should pay attention to in the effort to slow spending.
1) Source Credibility: Physicians have been shown to believe information from their own professional organizations more readily than the same information from insurance companies. Parents have been shown to heed vaccine advice from their child's pediatricians more readily than the same advice from government officials. Send messages from appropriate sources.
2) Incentives: People are "loss averse" and respond better to the fear of loss than the hope of reward. Awareness of this cognitive bias has been successfully applied to medication adherence and weight loss programs.
3) Norms: Peer group norms are powerful influences on behavior but they can be mispercieved. Alcohol consumption, for instance, was reduced in one study when educators communicated the actual norms of college drinking to students. They had believed that their peers were drinking much more than they actually were.
4) Defaults: At Vanderbilt University Medical Center setting an electronic prescription default to a generic drug worked better than traditional educational campaigns to get physicians to prescribe generic drugs.
5) Salience: Having salient cost information available to physicians has been shown to decrease the costs of the tests they prescribe.
6) Priming: Environmental factors have significant impacts on choices. Studies find, for example, that children exposed to food advertisements consumed 45 percent more calories than those who weren't exposed. Even simple environmental cues like larger plates increase food consumption.
7) Affect: Emotions play an important role in guiding our decisions. Asking patients to make important treatment decisions too soon after hearing bad news risks putting them at risk for a response based on transient fear, anxiety, and/or pain, rather a full assessment of the benefits and consequences.
8) Commitments: Self-commitment devices such as pre-paid gym memberships help people boost their willpower. Smoking cessation programs have used this technique with success by having quitters put money into a savings account which is only returned to them if they pass a nicotine-detecting urine test after six months.
9) Ego: Status among our peers is important to us. Hospitals that do better a providing high-quality, cost-effective services should have their performance publicized and recognized.
The One Minute Summary
Behavioral economics goes beyond the traditional assumption that we are all rational creatures who reliably make choices in our own best interests. Drawing on psychological research, it looks at the full set of drivers affecting our behavior. Often these are unconscious emotions, biases, preconceptions and tendencies. These ideas have already begun to be applied to patient safety efforts, but they could be more widely employed. The authors point out that ethical considerations, making sure that these levers are used to enhance people's critical choice-making rather than reduce it, are crucially important.
Read the Study: Approaches Based On Behavioral Economics Could Help Nudge Patients And Providers Toward Lower Health Spending Growth
By: Dominic King, Felix Greaves, Ivo Vlaev and Ara Darzi
Sunday, April 14, 2013
A Review of Studies Looking at Hospital Readmissions and ER Visits After Discharge Finds No Clear Path Out of the Woods
The Takeaway
1. Stephanie Rennke, MD at UCSF Medical Center led a team funded by the U.S. Department of Health and Human Services that reviewed studies on hospital-based interventions to reduce adverse events after discharge for medical patients. The results were published in the Annals of Internal Medicine on March 5.
2. Of 20, 248 studies published between 1990 and 2012, they were able to find 47 that looked solely at the general adult medical population to determine the effect of transitional care strategies on postdischarge emergency department use, hospital readmission or a combination of both.
3. The complexity of the intervention process and the variety of settings in which it has to be applied has meant that no clear single strategy has yet emerged that hospitals can be sure will reduce 30-day readmissions.
4. A number of institutions have had promising results using a "dedicated transition provider," (generally a nurse or a clinical pharmacist) who had primary responsibility for managing the discharge and follow-up process.
5. Project Red, which used a nurse discharge advocate in an urban "safety net hospital," and Care Transitions Intervention (CTI), which used a transition coach, were among the programs that did show significant reductions in adverse events 30 days post discharge. CTI was the only intervention that has already been scaled up to different types of hospitals and health care systems, and found effective.
6. The overall body of evidence is too weak so far to know how different interventions will perform in different organizations, each with their own safety and quality improvement cultures. Nor do we yet know which interventions will best scale-up for wider implementation across the country.
7. The financial onus is already on hospitals to reduce hospital readmission rates but in terms of evidence-based research, we are still in the stage of identifying best practices.
The One Minute Summary
With 20 percent of medical patients returning to the hospital or emergency department within 30 days after being released, reducing adverse events after discharge has become a priority for policy makers. The Partnership for Patients, a government/industry joint effort to increase patient safety and improve care, has identified hospital readmissions as one of its key focus areas. They are using a carrot and stick approach. The carrot is that under the Affordable Care Act, the Dept of Health and Human Services has been provided with $218 million to create Hospital Engagement Networks to identify best practices and help spread them across the health care industry. The stick is that the Centers for Medicare and Medicaid will now begin to reduce payments to hospitals that don't reach their targets.
In this context we should expect to see a lot of attention being paid to the problem of reducing readmissions, and a lot of fresh studies being published. Much of what has been done so far has focused on patients with specific diseases such as diabetes, asthma and heart disease. It is only logical that complex systems like hospitals should focus first on more easily defined groups. The results of those studies were excluded from this review because they wanted to see what has been applied to general medical population. The authors were not able to find much, nor would one expect them to. We are still in early days yet.
The good news is that interventions that begin in the hospital with patient education and review of medication changes, and are then "bridged" afterwards with follow-up phone calls, home visits or both, did reduce ED visits and readmissions by a significant amount. The bad news is that the effect was weak because the studies were too difficult to compare with one another. No standard way to measure results has yet been agreed on that can allow researchers in different health care settings, delivery systems, and communities to compare data. When this is developed policy makers will be able to ask the most pressing question: have these interventions been able to lower costs?
TL:DR "Bridging strategies" using nurse coaches, pharmacists or some other type of dedicated transition providers did reduce 30-day hospital readmissions in some cases. It's too soon to tell if this will be scalable or if it will save money.
Read the Study: Hospital-Initiated Care Interventions as a Patient Safety Strategy
By Stephanie Rennke, MD; Oanh Nguyen, MD; Marwa Shoeb, MD; Yimdriuska Magan, BS; Robert Wachter, MD and Sumant Ranji, MD.
The Takeaway
1. Stephanie Rennke, MD at UCSF Medical Center led a team funded by the U.S. Department of Health and Human Services that reviewed studies on hospital-based interventions to reduce adverse events after discharge for medical patients. The results were published in the Annals of Internal Medicine on March 5.
2. Of 20, 248 studies published between 1990 and 2012, they were able to find 47 that looked solely at the general adult medical population to determine the effect of transitional care strategies on postdischarge emergency department use, hospital readmission or a combination of both.
3. The complexity of the intervention process and the variety of settings in which it has to be applied has meant that no clear single strategy has yet emerged that hospitals can be sure will reduce 30-day readmissions.
4. A number of institutions have had promising results using a "dedicated transition provider," (generally a nurse or a clinical pharmacist) who had primary responsibility for managing the discharge and follow-up process.
5. Project Red, which used a nurse discharge advocate in an urban "safety net hospital," and Care Transitions Intervention (CTI), which used a transition coach, were among the programs that did show significant reductions in adverse events 30 days post discharge. CTI was the only intervention that has already been scaled up to different types of hospitals and health care systems, and found effective.
6. The overall body of evidence is too weak so far to know how different interventions will perform in different organizations, each with their own safety and quality improvement cultures. Nor do we yet know which interventions will best scale-up for wider implementation across the country.
7. The financial onus is already on hospitals to reduce hospital readmission rates but in terms of evidence-based research, we are still in the stage of identifying best practices.
The One Minute Summary
With 20 percent of medical patients returning to the hospital or emergency department within 30 days after being released, reducing adverse events after discharge has become a priority for policy makers. The Partnership for Patients, a government/industry joint effort to increase patient safety and improve care, has identified hospital readmissions as one of its key focus areas. They are using a carrot and stick approach. The carrot is that under the Affordable Care Act, the Dept of Health and Human Services has been provided with $218 million to create Hospital Engagement Networks to identify best practices and help spread them across the health care industry. The stick is that the Centers for Medicare and Medicaid will now begin to reduce payments to hospitals that don't reach their targets.
In this context we should expect to see a lot of attention being paid to the problem of reducing readmissions, and a lot of fresh studies being published. Much of what has been done so far has focused on patients with specific diseases such as diabetes, asthma and heart disease. It is only logical that complex systems like hospitals should focus first on more easily defined groups. The results of those studies were excluded from this review because they wanted to see what has been applied to general medical population. The authors were not able to find much, nor would one expect them to. We are still in early days yet.
The good news is that interventions that begin in the hospital with patient education and review of medication changes, and are then "bridged" afterwards with follow-up phone calls, home visits or both, did reduce ED visits and readmissions by a significant amount. The bad news is that the effect was weak because the studies were too difficult to compare with one another. No standard way to measure results has yet been agreed on that can allow researchers in different health care settings, delivery systems, and communities to compare data. When this is developed policy makers will be able to ask the most pressing question: have these interventions been able to lower costs?
TL:DR "Bridging strategies" using nurse coaches, pharmacists or some other type of dedicated transition providers did reduce 30-day hospital readmissions in some cases. It's too soon to tell if this will be scalable or if it will save money.
Read the Study: Hospital-Initiated Care Interventions as a Patient Safety Strategy
By Stephanie Rennke, MD; Oanh Nguyen, MD; Marwa Shoeb, MD; Yimdriuska Magan, BS; Robert Wachter, MD and Sumant Ranji, MD.
Thursday, March 28, 2013
Do Toyota's "Lean" Management Methods Work for Healthcare? New Study Says Yes
The Takeaway
1. Health economist K. John McConnel at Oregon Health and Science University led a study recently published in JAMA-Internal Medicine that found it is not only possible to apply Toyota-type quality improvement methods to health care, it leads to better outcomes.
2. The study looked at 597 hospital cardiac units in the US that operated catheterization laboratories.
3. Nurse managers were interviewed about 18 key performance practices in their organizations. They were asked to rate their units as poor, average or higher performers on each indicator. The researchers then gave each response a number from 1 to 5, with 5 being considered a "best practice."
4. Performance scores were divided into categories representing management goals: standardizing care/Lean operations, tracking key performance indicators, setting targets, and incentivizing employees.
5. Units with higher ratings had lower 30-day mortality ratings but they did not have lower 30-day readmission rates.
6. Because of its large sample size and the ability to rate different organizations in a consistent way, this study showed that Lean Management Methods can be used effectively in health care settings, not just in manufacturing.
The One Minute Summary
Back in the 1990s, Toyota's quality improvement program was being widely hailed by management gurus as the way to regain America's competitive advantage. It features worker/management teams, incentivized goals, and a focus on process and communication. Today, process-oriented quality improvement methods have become routine in American business but their adoption by health care organizations has been difficult to measure and evaluate. Now economists have come to the rescue. They have created a management practices evaluation tool that can compare quality improvement efforts at different organizations in a standardized way. The tool has been validated and shown to work in the health care setting. This particular study used the measurement tool to compare how different organizations were putting quality control practices to work in their cardiac catheterization units in 2010. They found a correlation between those that were rated as using the best management practices and lower 30-day risk adjusted mortality rates.
This study provides a good example of the way the social sciences and medical sciences can work together. Economists have learned how to measure and compare management practices. Their work provides a significant tool that health care planners can use to evaluate their own management practices. It should be applicable to all types of health delivery settings.
There is a lot of focus on reducing 30-day hospital readmission rates at the moment and, interestingly, this study did not find a correlation between the use of best management practices and lowered readmission rates. That finding does not look especially compelling given that there is no evidence that the hospitals being studied were actively engaged in targeted efforts to prevent readmissions. Had they done so, the results of this study may well have been more encouraging on that front.
Read the study: Management Practices and the Quality of Care in Cardiac Units
K. John McConnell, PhD; Richard C. Lindrooth, PhD; Douglas R. Wholey, PhD; Thomas M. Maddox, MD; Nick Bloom, PhD
The Takeaway
1. Health economist K. John McConnel at Oregon Health and Science University led a study recently published in JAMA-Internal Medicine that found it is not only possible to apply Toyota-type quality improvement methods to health care, it leads to better outcomes.
2. The study looked at 597 hospital cardiac units in the US that operated catheterization laboratories.
3. Nurse managers were interviewed about 18 key performance practices in their organizations. They were asked to rate their units as poor, average or higher performers on each indicator. The researchers then gave each response a number from 1 to 5, with 5 being considered a "best practice."
4. Performance scores were divided into categories representing management goals: standardizing care/Lean operations, tracking key performance indicators, setting targets, and incentivizing employees.
5. Units with higher ratings had lower 30-day mortality ratings but they did not have lower 30-day readmission rates.
6. Because of its large sample size and the ability to rate different organizations in a consistent way, this study showed that Lean Management Methods can be used effectively in health care settings, not just in manufacturing.
The One Minute Summary
Back in the 1990s, Toyota's quality improvement program was being widely hailed by management gurus as the way to regain America's competitive advantage. It features worker/management teams, incentivized goals, and a focus on process and communication. Today, process-oriented quality improvement methods have become routine in American business but their adoption by health care organizations has been difficult to measure and evaluate. Now economists have come to the rescue. They have created a management practices evaluation tool that can compare quality improvement efforts at different organizations in a standardized way. The tool has been validated and shown to work in the health care setting. This particular study used the measurement tool to compare how different organizations were putting quality control practices to work in their cardiac catheterization units in 2010. They found a correlation between those that were rated as using the best management practices and lower 30-day risk adjusted mortality rates.
This study provides a good example of the way the social sciences and medical sciences can work together. Economists have learned how to measure and compare management practices. Their work provides a significant tool that health care planners can use to evaluate their own management practices. It should be applicable to all types of health delivery settings.
There is a lot of focus on reducing 30-day hospital readmission rates at the moment and, interestingly, this study did not find a correlation between the use of best management practices and lowered readmission rates. That finding does not look especially compelling given that there is no evidence that the hospitals being studied were actively engaged in targeted efforts to prevent readmissions. Had they done so, the results of this study may well have been more encouraging on that front.
Read the study: Management Practices and the Quality of Care in Cardiac Units
K. John McConnell, PhD; Richard C. Lindrooth, PhD; Douglas R. Wholey, PhD; Thomas M. Maddox, MD; Nick Bloom, PhD
Friday, March 15, 2013
Useful Interactive Maps
If you are looking for teaching tools or just trying to find up-to-date information on health statistics and trends these interactive maps provide a wealth of data. They are all online and free.
The Dartmouth Institute for Health Care Policy and Clinical Practice has produced an excellent map using Medicare data. The Dartmouth Atlas allows users to create reports based on hospital referral regions (HHRs), hospital service regions (HSAs), primary care areas (PCAs), states, zipcodes, and even individual institutions. This is the go-to resource if you need information on utilization rates, medical discharges, or any of two dozen other topics and indicators. In addition to seeing it mapped, the site also allows you to bring up your data in the form of a table, bar graph, linear graph or age and sex distribution. One of the most useful features is that once you have found the data you need, you can download it to PowerPoint, or Excel, or you can create a PDF.
The Commonwealth Fund has created the Health System Data Center. It features a US map that measures a broad set of health indicators. It ranks regions by three different "scorecards," showing either the state system, child health care or local area rankings. Each scorecard can be broken down into a number of factors such as childhood obesity rates or the percent of children who received needed mental health care in the last year. This tool is useful for comparing health performance between one region and another. States can also be ranked individually. One limitation, with this map however, is that information is not available past 2009. This site also makes it easy to send your results to a PowerPoint slide or a PDF.
If you want to find out where quality improvement research is taking place, you will be interested in this map. Professor Ross Baker of the University of Toronto and Naomi Fulup of University College London led the team that researched and created it for The Health Foundation in the UK. Click on an icon at any point on this global scale map and you will be taken to that instistitution's website. The "scan" of health improvement science organizations found mostly academic centers and healthcare institutions gives a general snapshot of where improvement research is being conducted.
The Dartmouth Institute for Health Care Policy and Clinical Practice has produced an excellent map using Medicare data. The Dartmouth Atlas allows users to create reports based on hospital referral regions (HHRs), hospital service regions (HSAs), primary care areas (PCAs), states, zipcodes, and even individual institutions. This is the go-to resource if you need information on utilization rates, medical discharges, or any of two dozen other topics and indicators. In addition to seeing it mapped, the site also allows you to bring up your data in the form of a table, bar graph, linear graph or age and sex distribution. One of the most useful features is that once you have found the data you need, you can download it to PowerPoint, or Excel, or you can create a PDF.
The Commonwealth Fund has created the Health System Data Center. It features a US map that measures a broad set of health indicators. It ranks regions by three different "scorecards," showing either the state system, child health care or local area rankings. Each scorecard can be broken down into a number of factors such as childhood obesity rates or the percent of children who received needed mental health care in the last year. This tool is useful for comparing health performance between one region and another. States can also be ranked individually. One limitation, with this map however, is that information is not available past 2009. This site also makes it easy to send your results to a PowerPoint slide or a PDF.
If you want to find out where quality improvement research is taking place, you will be interested in this map. Professor Ross Baker of the University of Toronto and Naomi Fulup of University College London led the team that researched and created it for The Health Foundation in the UK. Click on an icon at any point on this global scale map and you will be taken to that instistitution's website. The "scan" of health improvement science organizations found mostly academic centers and healthcare institutions gives a general snapshot of where improvement research is being conducted.
Wednesday, March 6, 2013
SIBs Being Tested to Reduce ER Visits, Costs
 |
| Source: nhs.uk |
The Takeaway
1. Social Impact Bonds, also called "pay for success bonds," are an innovative funding method for community-wide health improvement and cost reduction.
2. The California Endowment is investing 1.5 million dollars on a pilot project in Fresno, CA to test whether in-home interventions can reduce ER visits and hospitalizations due to childhood asthma.
3. Applied to health care, the new funding method is being dubbed an HIB (Health Innovative Bond).
4. If they prove to have measurable impact and scalability, HIBs will offer a new way to pay for preventive care.
The One-Minute Summary
Social Impact Bonds (SIBs) are currently being used in Australia the United Kingdom, and New York City to fund broad-based social improvement projects that, in this age of narrow funding streams, might otherwise be difficult to finance. The idea is that local governments partner with private investors to issue bonds for a local project. The bondholders then contract with non-governmental service agencies to carry out the project. Investors get paid only when certain benchmarks are achieved. This gives the investors an incentive to monitor progress, and presumably, keep things on track. The local government pays the bond and taxpayers benefit by only paying for projects that have shown positive results. New York's Mayor Michael Bloomberg recently signed off on a pilot project to use an SIB to reduce recidivism rates at the Rikers Island men's facility (a jail). Now, this "pay for success" model is being applied to healthcare reform.
Rebecca Fairfax Clay described the first use of an HIB (Health Impact Bond) in an article for Environmental Health Perspectives. The California Endowment is putting up the initial money and Collective Health, a social enterprise organization is overseeing the project. The aim is to save money by reducing ER visits and hospital admissions for asthma sufferers in Fresno, CA. Asthma rates are particularly severe in this area; twenty percent of children in the county have been diagnosed with the disease. In the pilot phase of the study 200 children will receive preventive care in the form of home visits from community health workers. The program not only allows health workers to monitor medication compliance, it also pays for interventions such as removing carpets and cleaning up dust and mold. Backers expect to see a 33 percent reduction in ER visits and a 50 percent reduction in hospitalizations. The resultant savings are expected to be more than enough to offset the costs. Based on initial estimates, insurers will save 5,000 dollars for every child in the program.
Read the Article: Health Impact Bonds: Will Investors Pay for Intervention?
Monday, February 25, 2013
Hospital Readmission Rates Vary By Region
 | Regional Intensity of Care is Strongly Related to Risk of Readmission, Regardless of Illness Level |
| (Lenox Hill Hospital, 77th St. : By Daniel Case, Wikimedia Commons) |
The Takeaway
1. A nationwide survey of Medicare patients found that one in six medical discharges and one in eight surgical discharges resulted in a return to the hospital within 30 days.
2. Surgical patients released in areas with some of the the highest readmission rates [Manhattan (16%); White Plains (17.4%); and the Bronx, NY (18.3%)] were almost twice as likely to be readmitted as those in areas with the lowest rates [Bend, OR (7.6%); Boise, ID (8.4%); and Spokane, WA (9.5%)].
3. Avoidable readmissions were most likely to occur in regions where hospitals had the highest utilization rates.
4. Avoidable readmissions cost the government 17 billion dollars annually.
The One Minute Summary
Released on February 13, by the Robert Wood Johnson Foundation, and presented in an interactive map form by the Dartmouth Atlas Project, this study highlights the nation's lack of progress in addressing hospital readmissions. The authors looked at readmisison rates between 2008 and 2010 for states, hospital referral regions (HHRs) and 3000 individual hospitals. They sorted the population into two cohorts : those hospitalized with either surgicalproblems or medical problems. Three types of medical patients were also examined: those diagnosed with Pneumonia, Myocardial infarction or Congestive Heart Failure. Results were adjusted for age, sex, race and chronic illness mix. The report also included interviews with Medicare patients, nurses, family members and physicians.
Overall, the study found that there were no significant declines in 30-day readmission rates in any region of the country. The 2010 readmission rates were roughly the same as they had been in 2004 when the Dartmouth Atlas Project first started looking at the issue. The most important factor driving readmission rates was the local pattern of hospital utilization. Patients were more likely to return to in-patient care in regions where hospitals served as the main site of care. Patients were also likely to be readmitted due to illness level, the lack of availability of post-hospital care, and medication problems. A major stumbling block has been a lack of clarity about who should coordinate patient care following discharge. There is often poor communication between the discharge team, community physicians and non-acute care facilities.
This is disappointing news for many institutions. Since passage of the Patient Protection and Affordable Care Act hospitals have been under pressure to reduce readmision rates. The Centers for Medicare and Medicaid are now authorized to lower reimbursements to hospitals whose rates are higher than expected. In 2012 over 2000 US hospitals had their Medicaid payments lowered by 1 percent. Even higher penalties will be imposed this year unless hospitals can turn this around.
Read the Report: THE REVOLVING DOOR: A REPORT ON U.S. HOSPITAL READMISSIONS
Saturday, February 16, 2013
Quality Improvement Journals
Quality
Improvement Journals
|
How They
Describe Themselves
|
Open Access
|
|
British Medical Journal Quality and
Safety
|
“The new
look journal will integrate the academic and clinical aspects of quality and
safety in healthcare by encouraging academics to create evidence and
knowledge valued by clinicians and clinicians to value using evidence and
knowledge to improve quality.”
|
No
|
|
Clinical Practice Improvement
|
Sponsored by the Institute of Health
Care Improvement
|
No
|
|
Education for Health: Change in
Learning and Practice
|
“Open access e-journal
indexed on Medline”
|
Yes
|
|
Healthcare: The Journal of Delivery
Science and Innovation
|
“… cutting
edge research on innovation in health care delivery, including improvements
in systems, processes, management, and applied information technology.”
|
No
|
|
International Journal of Health Care
Quality Assurance
|
“…offers a definition of quality within the context of
health care, examines managerial and planning methods, discusses the
implications of introducing and maintaining quality initiatives, and
describes case histories. “
|
No
|
|
International Journal for Quality in
Healthcare
|
“…publishes papers in all disciplines
related to the quality and safety of health care, including health services
research, health care evaluation, technology assessment, health economics,
utilization review, cost containment and nursing care research, as well as
clinical research related to quality of care.” Published by Oxford Journals, a
division of Oxford University Press, UK.
Sponsored by the International society for Quality in Healthcare.
|
No
|
|
The Joint Commission Journal on
Quality and Patient Safety
|
Published monthly, The Joint
Commission Journal on Quality and Patient Safety is a peer-reviewed publication
dedicated to providing health professionals with the information they need to
promote the quality and safety of health care.
|
No
|
|
Journal for Healthcare Quality
|
“JHQ is a publication of the National Association for Healthcare Quality,
which seeks to be universally recognized as the leading resource for
healthcare quality professionals and an essential connection for leadership,
excellence, and innovation in healthcare quality. “
|
No
|
|
Quality Management in Healthcare
|
“Quality Management
in Health Care (QMHC) is a peer-reviewed journal that provides
a forum for our readers to explore the theoretical, technical, and strategic
elements of health care quality management. The journal's primary focus is on
organizational structure and processes as these affect the quality of care
and patient outcomes.”
|
No
|
|
Monday, January 28, 2013
The High Cost of Digital Mammograms
Newer Breast Cancer Screening Tools Such as CAD and Digital Mammography are Linked to Higher Regional Medicaid Costs without Evidence of Better Outcomes
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