August 16th, 2008 by Dr. Val Jones in Health Policy
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No one wants to become infected during their hospital stay. Unfortunately it’s not possible to guarantee that it won’t happen. Bacteria are everywhere. We carry them on our skin, in our bodies (especially our digestive tract), and they live in food, clothing, and anything we touch. When we undergo surgery, we cut through the skin/blood barrier that keep the bacteria out, making us vulnerable to inadvertent invasion.
There are ways to reduce the risk of infection (sterile surgical technique, appropriate wound care, and personal hygiene) but the risk is not zero. For the risk to be zero, one would have to begin with a “sterile” patient – a patient who carries no bacteria on or in their body. Since that will never happen, I’m afraid that hospital acquired infections are here to stay.
However, with government-sponsored health insurance programs on the brink of bankruptcy, decreasing expenditures is a high priority. Therefore, Medicare is suggesting that there are certain events that should never happen in the hospital and that they will no longer compensate hospitals for care associated with these events. Although I certainly agree that operating on the wrong body part is appropriately classified as a “never event,” the list has become so long that it includes things that cannot possibly be prevented in all cases (things like catching a cold, developing a blood clot, falling, or becoming infected).
What will result from listing infections as a “never event?” Will it encourage hospitals to improve their infection control processes? Maybe. But here’s what I imagine is more likely to happen:
1. More prophylactic antibiotics will be given to patients to reduce the risk of infection, resulting in higher rates of serious drug reactions. Stronger medicine (with broader coverage) will be preferentially selected – further encouraging the development of drug resistant strains of bacteria.
2. Patients who become infected will be transferred to another facility as quickly as possible. The accepting facility will be compensated for the care of the patient since the “never event” didn’t happen at their hospital. Transferring care in the middle of a serious illness increases the risk for other complications, including miscommunications and medication errors.
3. Since Medicare has set the expectation that hospital acquired infections are 100% preventable, anyone who contracts one will be able to sue the hospital. This will deplete the hospitals of their thin operating margins, causing them to cut programs – probably first for the poor and underserved.
4. Additional testing may be done for any surgical admission – nasal swabs (and potentially rectal swabs or urethral swabs) will be used to document the fact that the patient arrived at the hospital colonized by certain bacteria and therefore did not contract a new infection during their hospital stay.
5. Convoluted documentation methods will abound, so that any patient who becomes infected will receive antibiotics for “prophylaxis” and his fevers will be explained as the usual “post-op” central fevers. All staff will be encouraged to carefully document that the patient is being treated prophylactically only, and does not have an infection. In fact, it’s possible that blood cultures will not be drawn so that there will be no documentation of sepsis. Patients who really do have serious infections will receive appropriate care very late (since the first few days will be spent trying to manage the infection without documenting it or identifying the organism). This could paradoxically result in higher death rates.
6. Patients at higher risk for infection (such as those who are immunocompromised – see my research study on risk factors for line infections here) may be passed over for surgical procedures. This risk aversion could negatively impact health outcomes for vulnerable populations (such as cancer patients or HIV+ individuals).
I could go on theorizing, but you get the picture. In my opinion, the “never events” strategy is fatally flawed and will result in excessive litigation, ping-ponging of patient care, over-use of antibiotics, increases in adverse drug events, a rise in multi-drug resistant bacteria, and further reduction of services to the poor. A more reasonable approach would have been to document infection rates at the most hygienic facilities, and offer incentives for others to strive for similar rates.
The “never events” strategy is destined to do more harm than good for patients with hospital acquired infections, though the medical malpractice attorneys may enjoy a new income stream. This is just one more reason why we should never say never.
***
See Buckeye Surgeon’s take on this topic and his coverage of Jerome Groopman’s article for the New Yorker on the rise of drug resistant “super bugs.”
See Dr. Rich’s take on never events here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 9th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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What have doctors been witness to this week? Here are my top 10 choice tidbits:
Welcome to the wild world of medicine.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 28th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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I had the chance to interview Drs. Carmona, Satcher, and Novello about the current state of America’s war on cancer. I’ll post each conversation in a separate blog entry. This post explores Dr. Novello’s views on creating a healthcare navigation system for patients with cancer.
Dr. Val: How are cancer patients navigating the system currently?
Dr. Novello: They are relying primarily on their oncologists to help them navigate. But even though oncologists want to help their patients as much as possible, the reality is that they are taking care of thousands of patients at a time and simply don’t have the bandwidth to assist with the level of detail necessary.
Cancer is extremely complicated and patient care is not just about diagnosis, staging, and treatment. It also includes tests for genetic markers, coordination of genetic counseling, finding appropriate clinical trials for the patients to participate in, locating a continuity of care supervisor, rehabilitation services, scheduling chemotherapy, radiation, and surgical treatments.
Cancer doesn’t happen in a vacuum – patients also have other medical conditions that need to be managed along with the cancer diagnosis. In addition, one must create a comprehensive follow up plan for survivors, including scheduling of surveillance tests to identify possible recurrences. If a cure is not an option, then palliative care and hospice services must be coordinated. In addition to that, patients must create a living will, designate someone to have power of attorney over their care, and prepare for the legal aspects of their passing. This is why a diagnosis of cancer can be overwhelming to most people, and they are in desperate need of a structured program to help them navigate the complexities and to ensure that the ball is not dropped anywhere along the way.
Dr. Val: What’s the best way to help cancer patients more successfully navigate the healthcare system?
Dr. Novello: We need to create a simple, comprehensive, and accurate way to offer guidance to all Americans with cancer so that they can get the best care possible. You know how some hospitals have painted lines on the floor to help people to navigate from A to B in the building? Well we need this kind of line system for cancer care.
Ellen Stoval at the National Coalition for Cancer Survivorship, Lance Armstrong and his Foundation, members of the Institute of Medicine and the Centers for Disease Control and Prevention, and members of the President’s Cancer Plan at the National Cancer Institute, have formed a coalition to delineate the features of an ideal cancer patient navigator system. Senators Kennedy and Hutchison are preparing a bill for congress – it would ensure that Medicare covers a cancer patient navigator service. It remains to be seen who will build the service, and how it will be distributed.
Dr. Val: What are the key elements of a cancer patient navigator system?
Dr. Novello: The coalition is unanimous in their opinion that the navigator must provide culturally sensitive, clear information in the native language of the patient. A cancer patient navigator should include assistance with:
Diagnosis: Every patient needs to know the name and stage of the cancer that they have.
Treatment: The treatment plan (including chemotherapy, radiation, and/or surgery) that is recommended for them.
Scheduling: A schedule of all their appointments.
Pain Management: A comprehensive plan for pain management so that the patient is not denied access to narcotics if needed.
Psychosocial Services: Access to psychosocial services to assist with coping strategies for depression and family and marriage counseling.
Insurance Assistance: a plan for financing the cost of treatment – specifically an insurance advocate who can help the patient understand and maximize their insurance benefits, and if they’re uninsured, a way to get coverage for the care they need.
Peer Support: A list of support groups that can assist the patient with their emotional needs.
We need everyone to support this upcoming bill so that all cancer patients will have access to a navigation tool that will help them get the care they need in a timely fashion. Successful navigation of this healthcare system can mean the difference between life and death for cancer patients.
Dr. Novello is the Vice President for Women and Children’s Health Policy at Florida Hospital in Orlando, Florida.
*See the National Call to Action on Cancer Prevention and Survivorship*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 20th, 2008 by Dr. Val Jones in Expert Interviews
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This is part 2 of an interview with urologist Mark Schoenberg. Please click here for part one of the interview.
Dr. Val: How is bladder cancer treated?
Dr. Schoenberg: Bladder cancer can be grouped into two categories: non-invasive disease and invasive disease. About 80-90% of the time the cancer is formed by the cells of the inner lining of the bladder, ureters, and kidneys and is non-invasive. This type of bladder cancer doesn’t spread or invade the bladder wall, so it doesn’t threaten the life of the patient, but it can recur.
Non-invasive cancers are usually removed surgically via a scope that is inserted into the bladder via the urethra, and then afterwards there are a variety of medicines that can be infused into the bladder. Those medicines are like a kind of weed killer for bladder cancer.
Unfortunately up to 20% of patients have invasive tumors at the time that they are diagnosed. Once the bladder cancer has spread outside the bladder wall, surgery is needed to remove the primary tumor and then IV chemotherapy and sometimes radiation therapy are needed to treat the life threatening, metastatic disease.
Dr. Val: Is there any way to screen for bladder cancer?
Dr. Schoenberg: Unfortunately at this time urine tests for bladder cancer are very expensive, and they don’t detect cancer reliably. However, many researchers (including myself) are currently on a hunt for specific bladder cancer markers that are inexpensive and reliable. Once we find such a marker or group of markers, it would make sense to begin screening — at the very least — high risk groups such as smokers or people with occupational exposures to chemicals.
Dr. Val: What are the most promising advancements in bladder cancer treatment? Is there new research in the pipeline that could improve its diagnosis or treatment?
Dr. Schoenberg: There are two different areas of research interest in bladder cancer. The diagnostics arena — finding cancer more efficiently, effectively, and less invasively — and the therapeutics arena — developing new tools, drugs, and agents to get rid of cancer cells.
On the diagnostic front, molecular diagnostic researchers are looking at abnormal cancer proteins and DNA that can be detected in urine samples. Because of this research, in the next 5-10 years it wouldn’t surprise me if we no longer had to rely on cystoscopes for the diagnosis of bladder cancer. Also we’d like to develop molecular and genetic profiles in order to risk-stratify people more successfully (i.e. figure out who is at greater risk for bladder cancer, and make sure they get tested).
On the treatment front, there are a number of companies developing targeted therapies for bladder cancer. It’s possible that these therapies will reduce the risk of progression and recurrence in people with bladder cancer.
Unfortunately, bladder cancer has only attracted a fraction of the research dollars that other cancers have in patients in the same demographic (like pancreatic cancer). In fact, NIH funding for bladder cancer research is pitifully small and shrinking, despite the fact that there are 600,000 Americans who have bladder cancer right now. Not only that, but bladder cancer is one of the most expensive cancers to treat – because it requires repeated cystoscopies, catheter-based infusions, repeat surgeries, and sometimes chemo and radiation. Bladder cancer treatment costs Americans about 1 billion dollars a year.
Dr. Val: Why isn’t bladder cancer receiving the research funding it deserves?
Dr. Schoenberg: Successful cancer groups have highly visible champions for the disease – like Lance Armstrong for testicular cancer, or Susan G. Koman for breast cancer. Research funding seems to be strongly influenced by highly visible people getting out there and making a ruckus. We need powerful spokespeople to help Diane Quale at the Bladder Cancer Association Network to get the word out.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 30th, 2008 by Dr. Val Jones in News
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I read a touching story at the BBC news center about a young woman with Alpert’s Syndrome. This rare syndrome is present in only 1 in 170,000 births. It results in facial disfigurement and mitten-like hands.
The physical defects of Apert’s syndrome were first described by Fredrick Apert in 1942. These characteristics include: A tower-shaped skull due to craniosynostosis (premature fusion of the sutures of the skull)—an underdeveloped mid-face leading to recessed cheekbones and prominent eyes, malocclusion (Faulty contact between the upper and lower teeth when the jaw is closed) and limb abnormalities such as webbing of the middle digits of the hands and feet.
Bones of the fingers and toes are fused in Alpert’s infants giving a “mitten-like” appearance of their hands. Children with Apert’s syndrome can have unusual speech characteristics such as hyponasal resonance due to an under-developed mid face, small nose and long soft palate and, sometimes, cleft palate.
What struck me about the girl’s story was how she described how it felt to be teased growing up, and how the worst part of the teasing was that no one stuck up for her. I’ve seen kids do this kind of thing before, and I can imagine how painful it is when no one has the courage to go to bat for you. I’ve often wondered how “doing nothing” to defend a little one might be just as bad as actively harrassing them. I’d encourage parents to teach their children not to tease others, and beyond that, to come to the defense of those being teased. I bet this will do a lot of psychological good for the victims.
The good news in this case is that the girl has had some very successful reconstructive surgery and has a fairly normal life. The teen is even thinking about boyfriends, and preparing for college. Many thanks to the surgeons who did such a wonderful job.
And coincidentally, the Happy Hospitalist brought this story to my attention: a 4 month old kitten was in a horrible accident that resulted in her losing the front half of her face. Veterinarians were able to save her life, though she remains quite deformed. I am told that the kitty is not in any pain, and is enjoying her life as a therapy pet. She brings hope to those recovering in the hospital from surgeries and serious illnesses. I suppose they see her as a loving animal who is cheerfully going about her kitty business, without giving much thought to her previous injury.
These stories of hope are made possible by the surgeons and veterinarians who devote their lives to saving face. In so doing, they provide the rest of us with valuable lessons, and new friends of exemplary courage.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
