June 10th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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The OSHA-ization of health care quality continues.
A research group and a consulting firm have been hired by the state of Massachusetts to head up a new initiative to publish cost and quality information on Massachusetts doctors. But the quality measures they will use are the same old ones we have seen for a long time. They mean very little to most patients, and even less to doctors as a measure of how good their work may be.
To understand what I mean, look at what is being measured.
For the category “Adult Diagnostic and Preventative Care,” there are only four quality measures. They are:
- rates of colorectal screening tests
- the number of patients in an insured population who lowered their blood pressure in a given year
- correct imaging test use for lower back pain
- rates of use of a spirometry test for COPD
The good news is Massachusetts doctors do better than the national average on these measures. The bad news is it’s hard to say what that means as far as how good any doctor is who is measured this way.
Maybe it’s better in women’s health. There, the four quality measures are:
- rates of breast cancer screening for women 40-69
- rates of cervical cancer screening for women 21-64
- rates of chlamydia screening for women 16-20
- rates of chlamydia screening for women 21-25
Hmm. So if I am a 30 year-old woman trying to figure out how good my doctor is, the only thing that is being measured is whether he does a cervical cancer screening on me or not. How about pediatrics?
- rates of well visits
- correct antibiotic use for upper respiratory infections
- follow-up with children starting medications for ADHD
I could go on, but there’s a pattern. All of these “quality” measures are crunching medical billing data and styling it as a quality metric. And so every metric is going to be focused on things that are easily measurable by a review of those bills.
But there’s a more disturbing pattern. The information is simply not valuable to consumers. Worse, I think it is deeply misleading. A medical group that does chlamydia screenings on 100% of its patients may be good or bad – or it just may be smart enough to know that if they do the state of Massachusetts will rate them with five gold stars. But consumers won’t be able to tell the difference. All they will know is that practice A is “high quality,” while practice B isn’t. Some doctors are starting to sound the alarm about this.
And this is the larger point. Our health care is organized in a way that systematically undervalues the thinking, processing and deciding aspects of medicine- the things that really matter to you when you’re a patient who is sick trying to get help. Our system treats medicine as an assembly-line process amenable to assembly-line metrics. But it’s not.
Doctors, like others in professions requiring judgment and reflection, need time to think, and ought to be judged by how well they do that. Since the leading cause of misdiagnosis is a failure of synthesis – a failure by the doctor to put together available information in a way that leads them to the right conclusion – our system ought to be built around helping make sure this happens each and every time.
So, instead of a web site where you could see how often a medical practice does chlamydia screenings, imagine you could find out how often doctors at a hospital got their patients the right diagnosis and treatment? Now that would be a useful way to measure quality.
*This blog post was originally published at See First Blog*
June 9th, 2009 by Dr. Val Jones in Health Policy, Humor
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I’ve been attending a series of health policy conferences recently – and twittering them live. I’ve heard a lot of smart ideas and a lot of not-so-smart ideas. For your consideration, I offer you my best and worst recent health policy quotes:
The best quotes:
1. Evan Falchuk, Best Doctors: “Since the leading cause of misdiagnosis is a failure of synthesis – a failure by the doctor to put together available information in a way that leads them to the right conclusion – our system ought to be built around helping make sure this happens each and every time.”
2. Aneesh Chopra, Federal CTO: “HIT should not be in a box unto itself – put in a corner, making a capital-sucking sound.”
3. Clay Shirky, New Media Guru: “The problem is that, since we all die eventually, everyone will be unhappy with their healthcare at some point. This creates a social dilemma that’s neither transitory nor small. First, there will always be snake oil salesmen peddling ‘eternal life,’ and second, there will always be an unhappy faction who rail against the medical establishment.”
4. Joshua Ofman, Amgen, on comparative clinical effectiveness research: “We don’t want 2 different evidence standards. One to gain market access and a second to lose market access… There is a role for observational data to gain insights. There is a great allure of large, readily accessible databases that are fast – but the power and speed cannot overcome bias and confounding. ”
5. Vivek Kundra, Federal CIO: “We need to bake security into the architecture that we purchase from the private sector. The sprinkler system is part of any house you purchase – you don’t have to add it later.”
The Worst Quotes:
1. Senator Tom Harkin: “The NCCAM has failed to do their job of validating complementary and alternative medicine therapies.”
2. Senator Max Baucus: “Going to the doctor is like buying a car, except buying a car is a lot more fun.” Bonus quote: “If men liked shopping, they’d call it research.” [???]
3. Theresa Cullen, CIO, Indian Health Service : “At some point we’ll have to tell providers ‘you have to use EHR, we’ve drawn a line. If you don’t use it you’ll have to leave.'”
4. Sean Tunis, Center for Medical Technology Policy: “Randomized Clinical Trials can be designed with generous inclusion and exclusion criteria. Their limited inclusion criteria are not a permanent defect… We can’t wait 5 years for RCTs to be done. We have to find new methods that we can use (a “silver level of evidence” rather than the RCT “gold level”) to help inform our care decisions.”
5. Congressman Pete Stark: “I’m sick of rich doctors driving up in their Porsches saying ‘I’m pulling out of Medicare.’”
June 9th, 2009 by KevinMD in Better Health Network
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The military is learning from the dead.
In the past five years, every soldier who was killed in Iraq and Afghanistan has been given a CT scan. Why? In the hopes of creating a database of war injuries, which can be used to better equip and treat future soldiers.
The effort has already paid dividends. While examining the data, it was noticed that chest tubes used to treat pneumothoraces in the field were too short. The standard tubing would have been appropriate for 50 percent of soldiers, versus longer tubing that would fit 99 percent.
Also, it was because of these “autopsy scans” where it was noticed that many of the troops died from wounds in the upper torso, which could have been prevented with the appropriate body armor. On the basis of these findings, the military rushed more armor plates to Iraq.
It’s an interesting piece, and goes on to discuss the sensitive implications of the findings to family members:
The possibility that a relative burned to death is a particular source of anguish for families, and one area in which CT can outperform an autopsy. In a body damaged by flames, CT can help pathologists figure out whether the burns occurred before or after death. The scans can also tell whether a person found in water died from drowning.
It’s truly remarkable to see how much that can be learned after death.
*This blog post was originally published at KevinMD.com*
June 9th, 2009 by RamonaBatesMD in Better Health Network, News
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I want to say these two stories were well done (both aired on June 1, 2009). I was actually interviewed, but not quoted, for the story on fat-grafting. I pointed Allison Aubry to Dr Scott Spear as her expert. He is involved in one of the U.S. studies on breast augmentation using fat grafting.
Sculpting the Body with Recycled Fat by Allison Aubry.
Doctors Still Unsure Of Long-Term Risks
Surgeons like Dr. Scott Spear of Georgetown University Hospital want to know more about the techniques used to transfer fat for breast augmentation.
“We’re at the beginning of the learning curve,” he says. He has initiated a clinical trial to answer some questions about the best way to perform the procedure and whether there are any measurable risks. To date, there are no published studies in the United States, so doctors are relying on their own clinical experience.
Silicone Injections May Harm Some Patients by Patti Neighmond
When people get injected with silicone at pumping parties, Gorton says “there is no way to verify if they’re using medical-grade silicone. You can go to hardware stores and buy a big tub of it,” he says. “The element is the same, but it’s just not the same safety or purity or quality.”
*This blog post was originally published at Suture for a Living*
June 9th, 2009 by Bryan Vartabedian, M.D. in Better Health Network
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Let’s face it, Twitter isn’t that hard to figure out. The interface is intuitive and a little time on the application makes its basic function pretty obvious. But there are a couple of things that medical newbie’s might keep in mind before taking the leap on to Twitter. While I didn’t find myself in any kind of trouble, I had to figure a few things out on my own.
1. Follow and listen. Twitter is as much about listening as it is about talking. The best thing you can do to see how doctors are using microblogging to advance their platforms, practices and passions is look and listen. Pick a group of doctors (look at my follow list for some ideas) and follow them for a couple of weeks to see exactly what they do and how they interact with others. Don’t reinvent the wheel.
2. Goof around now, but ultimately think how you want to use it. You likely won’t have any idea about how to use Twitter when you first jump in. And that’s okay. You can’t understand it’s power until you reach a sweet spot of followers and cultivate relationships that have some history and meaning (in Twitter terms, of course). Ultimately you do want to think about connecting with those who will put you where you want to be – whether it’s just raising your profile as an author or specifically drawing patients for lapband surgery, or whatever. But also keep in mind that you may start by goofing off and never stop … like me.
3. You can follow whoever you darn well please. The world is full of self-ordained social media experts who spend their days working to make you feel like you don’t follow enough people. If you’re a physician with a real job you’re too busy to follow 30,000 people. Keep your eye on the ball and think about the network you want to develop. Whatever you do, don’t believe the nonsense that it’s ‘bad etiquette’ to not follow someone who follows you.
4. Your patients and your hospital are listening. Social media is interesting. While we type in the privacy of our boxer shorts, the world reads what we write. And that includes your patients. While my grandmother used to tell me before going out, ‘don’t do anything you wouldn’t do in front of the Virgin Mary, I’m telling you, don’t Tweet anything you wouldn’t want your patients to see. You represent your personal brand, practice, and profession with that very first tweet. Keep in mind that some hospitals have social media/blogging policies. You might look into this before taking the plunge. If you keep your hospital/institution off your bio, commit to never discuss anything relating to patients and always vow to be a really nice guy you should be good.
5. What happens on Twitter stays on Twitter. Remember that everything you type will remain etched in the infosphere for eternity. This can be retrieved by future employers, partners, soon-to-be-ex-spouses or anyone else interested in seeing or exploiting what you’re really about. Exercise intelligent transparency. Be smart and use your frontal lobe before hitting ‘update’.
I was interviewed by the AMA News last week on doctors and Twitter and that’s what got me thinkin’ about this post. I get a charge out of helping doctors recognize the power of connecting beyond their immediate environment. I hope this helps.
*This blog post was originally published at 33 Charts*
