Wednesday, April 13, 2011

Healthcare: More Notes from the Dark Side

There are so many things wrong with our healthcare system that one is almost tempted to feel optimistic: “With all of these easily correctable problems we should be able to cut back costs enormously with little required investment.” We shall see.

Laura Landro has an article in the Wall Street Journal: The Secret to Fighting Hospital Infections. She interviews a Dr. Pronovost.
“Dr. Pronovost's current crusade is preventing deadly bloodstream infections linked to central lines or catheters used in intensive-care units. A pilot project in Michigan showed that participating hospitals reduced rates of infections and death by using a checklist of evidence-based steps to reduce the infections—and by fostering a culture of safety and teamwork.”
When asked about the his goals and the problem he has had getting agreement to use the checklist Pronovost replied:
“The pilot who neglects a checklist before take-off would not be allowed to fly, and most safe industries have transgressions that are firing offenses. … But there hasn't been that kind of accountability in health care.”

“Nurses and pharmacists work for the hospital, which typically has clear lines of authority and procedures for dealing with failure to follow accepted practices. But physicians are often self-employed, have little training in teamwork and, perhaps like all of us, are often overconfident about the quality of care they provide, believing things will go right rather than wrong. Nurses are often reluctant to question them, and hospitals don't pressure physicians about teamwork for fear of jeopardizing the business they bring to the hospital.”

“The Department of Health and Human Services has called for a 50% reduction in central-line bloodstream infections over three years, but in some states only 20% of hospitals have signed up. We know bloodstream infections kill 31,000 people a year in the U.S., almost as many people as who die from breast cancer. While many hospitals have reduced infection rates, some have infection rates that are 10 to 15 times the national average. Some are content to meet the national average, despite evidence that these rates may be reduced by half.”

“What is perhaps most concerning is when I ask nurses, "If you saw a senior physician not comply with the checklist, would you speak up and would the physician comply?" Uniformly, the answer is no.”
And what exactly is this dreaded checklist that is so odious and troublesome that doctors would rather not bother with it?


Cheryl Clark for HealthLeaders Media reports on some findings by the Dartmouth Atlas Project which indicate that the types of treatment that doctors generally provide for certain medical conditions varies dramatically from location to location.
“For example, ‘there is little evidence that surgery is better than non-surgical treatment for chronic or persistent non-specific low back pain in patients who do not also have leg pain.’ Often the pain goes away on its own, yet surgery is risky and often patients are no better – and sometimes worse off – than before.”

“Nevertheless, rates of back surgery vary six-fold, depending on what part of the country a patient happens to reside. For example in Casper WY, surgeons perform 10 surgeries per 1,000 Medicare patients while in Honolulu, the percent is 1.7 and across the U.S., the rate is 4.3.”

“A similar story unfolds with stable angina. Patients so diagnosed have the option to be treated with medications and lifestyle change or with medications, stenting, or surgery.”

“But there is a trade-off. Stenting and surgery carry their own short-term risks, such as stroke, heart attack, and death. Yet in Elyria Ohio, beneficiaries are 10 times more likely to undergo percutaneous coronary intervention than those in Honolulu. And patients in McAllen, TX are four times more likely to undergo a coronary artery bypass graft procedure than those in Pueblo, CO.”
There are a number of conclusions one can draw from these results. Clearly one can assume that the doctors do not know what is the best treatment for certain conditions. That may be non-culpable ignorance, and doctors provide the treatment with which they are familiar.

The Dartmouth report (Improving Patient Decision-Making in Health Care) suggests there other factors at work. They accuse doctors of neglecting to fully inform patients of what all the treatment options are and what the possible consequences might be. The doctor believes he/she knows best and encourages the patient to follow his/her advice. This is referred to as “Doctor Centric Care.”
“....'often these physicians are quite unaware that they practice differently from a quite similar community halfway across the country,' Goodman says.”

“The researchers emphasize they are not suggesting that physicians are just trying to generate income and volume, although that may, in some cases, underpin the rationale behind a more aggressive course of care.”

“Rather, they say, it's about making sure the patient is fully informed of all the pros and cons of every treatment option – surgical and non-surgical—and they are fully informed about the benefits and risks, recovery periods, perforations, risk of stroke and even death from having an invasive procedure versus taking drugs and changing their lifestyle.”

“Here's an example of how doctors aren't correctly informing patients, Barry continues. When a large cohort of Medicare patients who had undergone elective stent procedures for chest pain or stable angina were asked why they had the procedure, ‘three-fourths said, “I did it to prevent a heart attack or to live longer”' But we have randomized trials with tens of thousands of patients that say that's not what stenting is about. It can reduce angina, although patients treated medically can catch up over a couple of years," Barry says.”

“Meanwhile, stenting in and of itself carries risks of generating clots or strokes, heart attacks, and even death.”

“Barry points out that in studies that made sure patients had all information about procedures available for their conditions, they were 20% more likely to make more conservative decisions than their doctors recommended.”
One of the study authors provides an appropriate conclusion.
“....there are two underlying ethical principles at work in the delivery of care. One is the duty of the physician to do what the physician believes is in the best interest for the patient. But the second is to respect that the individual has a right to say what will happen to his or her body. ‘We have an ethical obligation to respect that autonomy ... But we have allowed habit, bias, and financial incentives to creep into this equation’."
Finally, there is a Reuters article by Julie Steenhuysen. A study that appeared in Archives of Internal Medicine indicated that panels of experts assembled to provide treatment guidelines for heart patients often have conflicts of interest.
“Of the nearly 500 people studied, 56 percent reported a conflict of interest. The most common conflicts included being a consultant or serving on a company advisory board, followed by getting a research grant, taking money for serving on a speakers' bureau and owning stock.”

“Even though the experts are disclosing their ties to companies that produce heart drugs and devices, the phenomenon is important because the guidelines they produce are used to help train new doctors, thus can have long-lasting impact on the way patients are treated.”

"’Because they are so important, the process for producing them is also important. They need to be above suspicion,’ said Dr. James Kirkpatrick of the University of Pennsylvania, who worked on the study....”
And the conclusion to be drawn from these findings:
“....the study highlights ‘troubling concerns that must be urgently addressed. If we fail as a profession to police our clinical practice guideline process, the credibility of evidence-based medicine will suffer irreparable harm’."

“....part of the argument for allowing people with conflicts to serve on these panels is that it is difficult to find qualified heart experts who do not have any conflicts.”

Another sigh....

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