November 9th, 2008 by Dr. Val Jones in Medblogger Shout Outs, Opinion
2 Comments »
As many of you know, I’ve been pretty upset about the “never events” policy put forward by CMS. That’s because they took a theoretically reasonable punitive rule (Medicare will not pay hospitals for patient care related to gross medical errors, aka “never events,” like wrong-side surgery) and made it far too general (never events include delirium, falls, and any infection – even a cold). It is absolutely impossible to prevent these sorts of things 100% of the time. So how should “never events” be defined?
The Happy Hospitalist nails it:
Can the never event happen at home? If the answer is yes, it cannot be a never event. It is a natural event. Even the criminal events that nobody can foresee are considered never events. Tell me how a hospital can prevent a random crazy family member or hospital guest from going berserk and assaulting an employee or patient. It’s impossible to predict or prevent.
November 8th, 2008 by Dr. Val Jones in Celebrity Interviews, Expert Interviews
8 Comments »
 |
|
Dr. Gawande
|
Kaiser Permanente sponsored a special event in DC today – Charlie Rose interviewed Dr. Atul Gawande about patient safety in front of an audience of physicians. Dr. Gawande is a young surgeon at Harvard’s Dana Farber Cancer Institute, has written two books about performance improvement, and is a regular contributor to the New Yorker magazine. I had heard many positive things about Atul, but had never met him in person. I was pleasantly impressed.
Atul strikes me as a genuinely humble person. He shifted uncomfortably in his chair as Charlie Rose cited a long list of his impressive accomplishments, including writing for the New Yorker. Atul responded:
I’m not sure how my writing became so popular. I took one fiction-writing class in college because I liked a girl who was taking the class. I got a “C” in the class but married the girl.
He went on to explain that because his son was born with a heart defect (absent aortic arch) he knew what it felt like to be on the patient side of the surgical conversation. He told the audience that at times he felt uncomfortable knowing which surgeons would be operating on his son, because he had trained with them as a resident, and remembered their peer antics.
Atul explained that patient safety is becoming a more and more complicated proposition as science continues to uncover additional treatment options.
If you had a heart attack in the 1950’s, you’d be given some morphine and put on bed rest. If you survived 6 weeks it was a miracle. Today not only do we have 10 different ways to prevent heart attacks, but we have many different treatment options, including stents, clot busters, heart surgery, and medical management. The degree of challenge in applying the ultimate best treatment option for any particular patient is becoming difficult. This puts us at risk for “failures” that didn’t exist in the past.
In an environment of increasing healthcare complexity, how do physicians make sure that care is as safe as possible? Atul suggests that we need to go back to basics. Simple checklists have demonstrated incredible value in reducing central line infections and surgical error rates. He cited a checklist initiative started by Dr. Peter Pronovost that resulted in reduction of central line infections of 33%. This did not require investment in advanced antibacterial technology, and it cost almost nothing to implement.
Atul argued that death rates from roadside bombs decreased from 25% (in the Gulf War) to 10% (in the Iraq war) primarily because of the implementation of check lists. Military personnel were not regularly wearing their Kevlar vests until it was mandated and enforced. This one change in process has saved countless lives, with little increase in cost and no new technology.
I asked Atul if he believed that (beyond check lists) pay for performance (P4P) measures would be useful in improving quality of care. He responded that he had not been terribly impressed with the improvements in outcomes from P4P initiatives in the area of congestive heart failure. He said that because there are over 13,000 different diseases and conditions, it would be incredibly difficult to apply P4P to each of those. He said that most providers would find a way to meet the targets – and that overall P4P just lowers the bar for care.
Non-punitive measures such as check lists and applying what we already know will go a lot farther than P4P in improving patient safety and quality of care.
Atul also touted the importance of transparency in improving patient safety and quality (I could imagine my friend Paul Levy cheering in the background). In the most touching moment of the interview, Atul reflected:
As a surgeon I have a 3% error rate. In other words, every year my work harms about 10-12 patients more than it helps. In about half of those cases I know that I could have done something differently. I remember the names of every patient I killed or permanently disabled. It drives me to try harder to reduce errors and strive for perfection.
Atul argued that hospitals’ resistance to transparency is not primarily driven by a fear of lawsuits, but by a fear of the implications of transparency. If errors are found and publicized, then that means you have to change processes to make sure they don’t happen again. Therein lies the real challenge: knowing what to do and how to act on safety violations is not always easy.
 |
|
Charlie Rose
|
Charlie Rose asked Atul the million dollar question at the end of the interview, “How do we fix healthcare?” His response was well-reasoned:
First we must accept that any attempt to fix healthcare will fail. That’s why I believe that we should try implementing Obama’s plan in a narrow segment of the population, say for children under 18, or for laid off autoworkers, or for veterans returning from Iraq. We must apply universal coverage to this subgroup and then watch how it fails. We can then learn from the mistakes and improve the system before applying it to America as a whole. There is no perfect, 2000 page healthcare solution for America. I learned that when I was working with Hillary Clinton in 1992. Instead of trying to fix our system all at once, we should start small and start now. That’s the best way to learn from our mistakes.
October 29th, 2008 by Dr. Val Jones in Health Tips, Medblogger Shout Outs
No Comments »
My friend and fellow blogger Kerri Morrone Sparling (at the Six Until Me blog) was diagnosed with type 1 diabetes when she was in second grade. The diagnosis came a few short weeks before Halloween, and back then she didn’t realize the risks of sneaking candy bars behind her mom’s back.
Now that Kerri’s grown up, she has some excellent tips for parents of children with type 1 diabetes (or frankly, for anyone who wants to enjoy Halloween and manage their diabetes). You should check out her video blog on the subject here.
Some tips include:
1. Focus on the costume part of the holiday, not the candy part.
2. Make some “candy” corn with Splenda, Equal or a sugar substitute. Enjoy the salty-sweet treat instead of a Snicker’s bar (for example).
3. Work in a small amount of candy into your diet plan. Eat a half a candy bar during a period of high activity, for example, and the sugar spike will not be so bad.
Please check out Kerri’s post for more tips!
***
And for a good laugh about candy, check out The Onion’s headline here.
October 29th, 2008 by Dr. Val Jones in Celebrity Interviews
No Comments »
 |
|
Joan Lunden
|
Former Good Morning America host, Joan Lunden, is getting behind the personal health record industry. As the daughter of a physician, Joan grew up believing that she’d become a doctor one day. She told me that all that came to a screeching halt when she “realized that she didn’t like blood or stitches.” But Joan has always kept women and children’s health advocacy initiatives close to her heart. She will soon be starring in a new Lifetime TV show called Health Corner. I caught up with her about her recent work with PassportMD.
Listen to the podcast here, or read a summary of our discussion below.
Dr. Val: Tell me about your experiences in taking care of your mom, and what led you to become involved with a PHR company.
Lunden: I lost my brother to type 2 diabetes a little over a year ago. As it happens, he had been managing my mom’s medical care, and so with his loss I needed to step in and take it over. Of course she lives on one coast and I live on the other. I’ve got 4 little kids (two sets of twins) and three young adult children. It becomes really daunting to keep track of everyone’s medical care. Around that time I met some folks from PassportMD, and when they showed me how easy it could be to keep everyone’s records in one place, I said, “this is exactly what I need.”
I think I’m really typical of a lot of women out there in what we call “the sandwich generation.” Today a high percentage of women with small children are working outside of the home. It’s really a lot to juggle – a career, raising a family, and getting everyone to the doctor on time – forget about getting YOU to the doctor on time. As good as we women are at nurturing others, we tend to be at the bottom of our own to-do lists.
What I really love about PassportMD is not just the organization (I can immediately see all my kids’ vaccination schedules for example) but the fact that I’m building a family medical history. It’s so important to know your family history so that you can engage in appropriate screening tests and take preventive health measures. This PHR even sends you reminders when its time for immunizations, mammograms, or other appropriate screening tests.
Dr. Val: As a doctor I’ve encountered resistance to PHRs from patients because they don’t want to have to enter all the data themselves. They’d like it to be auto-populated with their medical record data so that they don’t have to start from scratch. Has the PassportMD tool solved that problem?
Read more »
October 28th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
No Comments »
 |
|
Bert Rein
|
On November 3, 2008 the US Supreme Court will hear opening arguments in the Wyeth vs. Levine case. This highly publicized lawsuit has been discussed by the New York Times and the Journal of the American Medical Association and will likely be the most important case during the upcoming Supreme Court term. However, neither source has fully explained the unexpected consequences to the consumer if Wyeth loses.
To get to the bottom of the issue, I interviewed Bert Rein, attorney for Wyeth. Bert has conducted interviews with NPR and the three major TV news networks. Please enjoy this exclusive podcast interview here at Getting Better with Dr. Val, or read my summary of our conversation below.
Dr.Val: Bert, please summarize for our listeners what has happened so far in the Wyeth vs. Levine case.
Rein: Ms. Levine is a guitarist who suffers from migraine headaches and associated nausea. One day she sought pain management therapy at a clinic in northeast Vermont – the same clinic where she regularly received care. They elected to treat her with a combination of demerol (for pain) and phenergan (for nausea). They delivered the drugs intramuscularly, but several hours later Ms. Levine returned, complaining of an unrelieved migraine headache.
The clinic’s physician realized that the drugs would be more potent if they were injected intra-venously so he asked the PA (physician assistant) to give another dose of the drugs through Ms. Levine’s vein. Unfortunately, the PA inserted a butterfly needle (rather than the usual heplock for an IV) into what she thought was Ms. Levine’s vein, and delivered the phenergan into or near a punctured artery. Phenergan’s label clearly states that the drug can cause tissue necrosis if it comes in contact with arterial blood. Ms. Levine experienced a necrotic reaction to the medication which resulted in the eventual amputation of her arm. She sued the clinic for negligence and was awarded $700,000 dollars in a cash settlement.
Ms. Levine then brought a separate lawsuit against Wyeth, claiming that the phenergan label did not offer sufficient instructions about how to administer it safely, though the risks of necrosis from arterial blood exposure to phenergan are well known and labeled in capital letters as a warning on the drug’s label. Read more »
