Thursday, April 30, 2009

Whistle blowing is always risky,In Great Britain's NHS even worse,nurse looses a lot

See here for what happened to a nurse in England who dared to help let the public know how bad things were at one NHS service about which I have commented before in regard to the issue of how very wrong things can go when quality performance targets dominate the scene.

Monday, April 27, 2009

Two of my favorite medical bloggers seem to disagree regarding CER

When I read a recent blog posting by DB,who postings inspired me to start to blog and with whom I rarely disagree, I was sharpening up my blogging tools to respectfully offer a view counter to his, but as is often the case DrRW beat me to the draw (See here).

Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.

Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.

Dr. RW's final paragraph deserves much consideration:

No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.

Thursday, April 23, 2009

Still more thoughts on problems with EMRs and who or what is responsible for the patient

Here is a link to a discussion of more problems with electronic medical records (EMRs) that ties in with the issue of individual versus group responsibility.

The particular case involved a patient at an academic medical center in which

It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."

The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.

At bottom, the error got as far as it did because of the "medical team" approach - no single person was responsible for this patient's care. Each person relied on the (erroneous) electronic medical record for his view of the whole.

We seem to be replacing personal physician responsibility with "systems".

With so much rhetoric these days about instilling professionalism in medical students and house officers how can individual responsibility be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:

Physicians must recognize their obligation is not discharged at any given time or any given day.

No, that is not a typo -they eliminated what used to be considered a fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient

I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.

Earth Day -some cogent counterpoints to the standard green koolaid

The first thing I remember about Earth day were reports of some cases of histoplasmosis in a group of well meaning well-meaners who breathed in a bunch of fungal spores when they set out to clean up their little portions of the earth.

Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:

I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.

Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.

.. capitalism has. Through wealth generated by the free market, we have enough resources to move beyond the subsistence economies that damage the environment, enough disposable income to fund clean-up programs, enough wealth to scrub and polish industry.

Only in advanced economies can the technology needed to recycle hazardous waste or to replace dirty coal-fired power plants with cleaner gas or nuclear plants be developed. That technology cannot be produced in centrally planned economies where the profit motive is squelched and lives are marshalled by the state.

There's nothing wrong with setting aside a day to honor the Earth. In fairness, though, it should be complemented by Capitalism Day. It's important that the world be reminded of what has driven the environmental improvements since Earth Day began in 1970.

Wednesday, April 22, 2009

Health Insurance does not equal health care

Worth reading is this commentary by internist Dr. Marc Siegel who cautions that "health insurance does not equal health care".Neither is the promise of a government of universal coverage equal to the actual delivery or ready availability of health care.

Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.

A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.

Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.

There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part

"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "

My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.

Tuesday, April 21, 2009

In Canada health care is a right,wait ,no it isn't?

In Canada, there is universal health care with a single payer and for the most part no opting of the system.Their supreme court ruled that patient rights were been violated because their access to health care was in some instances so delayed that it was no care at all.

Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.

Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.

Sunday, April 19, 2009

More concerns about Government mandated and financed electronic medical records

To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)

Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.

While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.

Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.

Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.

Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.

Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.

Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.

I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.

We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.

Tuesday, April 14, 2009

Comparative effectiveness research-more warnings

Those, including several medical bloggers, who seem to have placed more than a little faith in the notion of a government funded and run comparative effectiveness research program (CER) should read the following sobering posting from Health Care Renewal.

The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.

“The goal,” Sebelius said, “is to provide every American with a safe, secure electronic health record by 2014." The nominee also endorsed efforts to use data gleaned from electronic medical records to conduct “comparative effectiveness research" (the authors bolding)(CER) to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”

The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.

It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.

First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.

Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.

Monday, April 13, 2009

Medical Home will not be enough, we need the Medical Village

I written before about my skepticism regarding the Medical Home concept.It has been suggested that the home does not go far enough and that a "village "concept should be explored and possibly adopted. Here is one doc's version of how that village concept would be applied to one aspect of medical care. Thanks to Dr. Hal Dall's blog for insightful comments and satire.

Tuesday, April 07, 2009

Statins (or at least one of them) seems to just get better and better

Just as we thought there could not possibly be any more purported benefits of the statin drugs we are treated to still another reason to get on the bandwagon- prevention of venous clots.

At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.

Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.

Monday, April 06, 2009

What the heck could increased variation in red blood cell size have to do with heart disease or mortality?

This article from the Archives of Internal Medicine seems to link a measure of variability in red blood cell (rbc) size with all cause mortality. As the article explains, previously there had several studies that suggested a link between heart disease and RBC size variability as judged by measurement of the RDW by automated blood cell analyzers. (See here for one article linking elevated RDW and adverse clinical outcomes in patients with heart disease). The Archive article examined a large data base for evidence of a similar correlation with all cause mortality and seemed to find one that reached statistical significance.

The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.

The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.

How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?

Thursday, April 02, 2009

Is the Massachusett Universal coverage plan the canary in the mine?

See this article from WSJ online to gather facts about how poorly things are working out in the grand universal health care program for Massachusetts.

Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.

Proponents had promised universal coverage with lower costs.

Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:

By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.

The WSJ article closes with:

The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.

At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.

We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?

Wednesday, April 01, 2009

NHS's hospital from hell showcases performance measures

The British NHS is investigating how things could go so very wrong at one of their hospitals,the Stafford hospital. See here for the newspaper report that puts at least part of the blame on a situation where mindless adhering to quality targets may have caused deaths.

See also here for the story that has this quote:

...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.

At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.

One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....

I have blogged before on Goodhart's law which says:

"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".

While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.