In the most recent issue of the New England Journal of Medicine, Dr. Thomas Bodenheimer defines the coordination of medical care as “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” Or, to put it in layman’s terms: doctors working together to get things right.

The value of this sentiment should be self-evident, but the coordination of medical care is more complex than it initially seems—even when discussing admittedly uncomplicated concepts. Consider the “hand-off,” that transitional moment when a patient is passed from one provider  to another (e.g. from primary care physician to specialist, specialist to surgeon, surgeon to nurse, etc)– or is discharged  This transition is unavoidable—as Bodenheimer points out, modern health care necessitates a “pluralistic delivery system that features large numbers of small providers, [which] magnif[ies] the number of venues such patients need to visit.” 21st Century  medicine is too complex for one-stop shopping.

Inescapable though it may be, the hand-off is fraught with pitfalls. As Quality and Safety in Health Care (QSHC), a publication of the British Medical Journal, noted in January, the simple transition of a patient from one caretaker to another represents a gap that is “considered especially vulnerable to error.”

Even the most common hand-off—your standard referral from primary care physician to specialist—is not risk-free. As Dr. Bob Wachter recently noted in his blog, “in more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation.” Sadly, the radio silence goes both ways: “in one-quarter of the specialty consultations,” Wachter says, “the primary care physician received no information back from the consultant within a month.”

These missteps are indicative of what can go wrong during the hand-off, such as, according to QSHC, “inaccurate medical documentation and unrecorded clinical data.” Such misinformation can lead to extra “work or re-work, such as ordering additional or repeat tests” or getting “information from other healthcare providers or the patient”—a sometimes arduous process that can “result in patient harm (e.g., delay in therapy, incorrect therapy, etc).”

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Berlin, March 13, 2008 —  By bringing 600 government and industry leaders together from more than 50 countries, the “World Health Care Congress Europe” (WHCCE),  which began Monday, offered  a splendid  window on  the wide variety of  solutions that countries  around the world are using as they struggle  toward health care reform. One constant theme of the conference: “No One Thing Works.”

When the three-day conference ended yesterday, it also was apparent that developed countries share many of the same problems.  One that stands out is the fact that our populations are aging. Each country faces the same question: how will a shrinking workforce possibly pay for the medicine their nations’ retirees will need?

This brings me to Princeton economist Uwe Reinhardt’s speech on the very first day of the conference. The only American to speak at WHCCE, Reinhardt focused on what he called “the folklore that people bring to the health care policy table.” By nature an iconoclast, Reinhardt spent the next 20 minutes shattering some of the myths that have become part of the received wisdom among policy-makers.

Begin with the notion that an aging population is a major factor driving health care inflation.  In the U.S. this is accepted as a justification for why the nation’s health care bill now equals more than $2 trillion dollars—and why we must expect it to climb ever higher.

Bad news is often more gripping  than good news, and  “if you want to be a popular speaker you need to feed the paranoia of your audience,” Reinhardt  observed, pointing to the first slide of his Power Point presentation—a  chart illustrating just how quickly we can expect a horde of wrinkly boomers to take over the nation. Some stooped and shriveled, others proudly bloated, these former members of the Pepsi generation will be far more demanding, we’re told, than the World War II veterans who preceded them.

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“The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not,” notes The Commonwealth Fund in “Aiming Higher: Results from a State Scorecard on Health System Performance.”

This comparative state-by-state study of care in the U.S. pops off the page as part of a report released this month, “Health Policy Reform: Beyond the 2008 Elections,” and explodes some myths about where the best care can be found.

Find your state on the map below. You may be surprised to discover that when it comes to overall performance, health care systems in states such as New York, California and Texas—places known for being home to some world-class academic medical centers—don’t turn up in the top quartile. (States that do rank in the top 25 percent appear in white).

Reputation is one thing; medical evidence about quality of care, access to care, unnecessary treatments, excessive costs and bad outcomes is another. U.S. News & World Report is good at many things; ranking hospitals is not one of them.

How did the researchers who drew this map rank states? They used the 32 indicators listed on the table below (click to open a larger version in a new window) which measure:

• “Access” (based on how many of the state’s adults and children have no insurance, and how many went without needed care)
• “Quality” (measured by yardsticks such as the percent of adults and children who receive recommended preventive care; the share of hospitalized patients who received recommended care for acute myocardial infarction, congestive heart failure, and pneumonia; the percent of surgical patients who received antibiotics at the right time to prevent infections; the share of Medicare patients who gave the treatment they received high marks and said their provider listened to them, explained, and showed respect; the percent of nursing home patients suffering from bed sores resulting from not having been turned often enough; and the share of nursing home patients who were strapped to their beds)
• “Potentially Avoidable Use of Hospitals and Cost of Care” (measuring how many patients were hospitalized who might not have needed hospitalization if they had received proper care in the first place– and the cost of those unnecessary hospitalizations)
• “Healthy Lives” (indicating the chance of living a long and healthy life in a given state based on the percent of deaths that might have been prevented if the patient had received good care, the percent of breast cancer deaths, colorectal cancer deaths, infant mortalities, and the share of seniors whose activities are limited due to physical, emotional or mental health problems)

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In the latest issue of the Journal of the American Medical Association (JAMA), the always-compelling duo of Ezekiel Emanuel and Victor Fuchs—associated with the National Institutes of Health and Stanford University respectively—dispel the myth of “shared responsibility” in health care financing.

What does this mean, exactly? Simple: “the common claim that employers, government, and households all pay for health care is false. Employers do not share fiscal responsibility and employers do not pay for health care.” In fact, the “money [for health care] comes from [our] own pockets.” 

As simple as this assertion may seem, it’s actually a ground-breaking statement. As Emanuel and Fuchs point out, most of the political rhetoric surrounding health care reform implies that everyone—individuals, employers, households, and governments—struggle with health care costs equally. Implicit in this formulation is a sad tale of businesses getting crunched: Because employers provide health coverage to most Americans who are insured, employers are often singled out as victims. It often seems like the health care crisis is their burden.

Indeed, “burden” is quite the buzzword here. Barack Obama says it’s a tragedy “when businesses have to lay off one employee because they can’t afford the health care for another.” Hillary Clinton notes that “large American companies compete in a global economy against companies in countries that impose far lower health care burdens on employers.” Congress celebrates reforms that supposedly “takes [the health care] burden off employers.” It certainly sounds like businesses have it bad. 

Not so fast, say Emanuel and Fuchs. We need to consider the “health care cost-wage tradeoff.” A large body of economic research shows that, when you crunch the numbers, employers don’t lose the money they spend on health care, but rather take the costs out of their employees’ paychecks. In fact, a 2004 study from the International Journal of Health Care Finance and Economics found that "the amount of earnings a worker must give up for gaining health insurance is roughly equal to the amount an employer must pay for such coverage."

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In Part I of this post,
I discussed the policy implications of recent research from Duke
University showing a clear link between mental disorders in children
and their criminal activity as adults. I particularly focused on the
impact quality child care and poverty reduction can have as a means of
improving mental health—and thus, potentially prevent crime. Part II,
which focuses on education, health care, and the juvenile justice
system, follows below.

But a high-quality continuum of mental health services can’t only
engage with preschoolers. The reality of life is that people develop at
different rates, and the kid who’s quiet at age 3 can become a
hell-raiser at age 9. As such, schools have become a particularly
important site of diagnosing and treating mental health problems among
children.

For all the problems public schools face today, there has been some
progress on the mental health front. The Substance Abuse and Mental
Health Services Administration (SAMHSA) reports that 70 to 80 percent
of children who receive mental health services get the aid from
school-based mental health service providers (e.g. guidance counselors,
school psychologists, etc). Many schools have coordinated programs of
education, observation, and counseling that partner up with community
health experts.

But there’s still a ways to go. The American School Board reports that
there are around 1,700 school-based health centers in the United
States, a tiny fraction of the nation’s nearly 90,000 public schools.
There are many reasons for the relatively small number of centers
including the basic difficulties that come with implementing what
experts call an "ecological" model of mental health. This is a fancy
way of saying that schools that are serious about mental health can’t
just have mental health resources; they must integrate those
resources—educational materials, counselors, information, activities,
etc—into the every day school environment (e.g. classes, discipline,
etc).

This is, as you might imagine, a costly undertaking, and research from
SAMHSA has found that low-income and minority schools are far less
likely to have mental health programs in place. Those that do often
have very limited programs.

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There’s one issue that hasn’t seen much airtime during the Presidential election, and you probably didn’t even realize its absence. That issue is crime, and it hasn’t come up because it’s just not as scary as it was in the past. In one of the great mysteries of criminology, crime began to fall in 1993 and continued to plummet throughout the 1990s and into the 21st century.

Experts have offered explanations ranging from higher incarceration rates to more cops on the streets to the legalization of abortion (this last theory, put forth by economist Steven Levitt in the best-selling Freakonomics, has since been disproved). But ultimately no one can pinpoint exactly what happened, mostly because no one really knows what causes crime as a broad, social phenomenon. If we can’t explain what causes it, we can’t understand what causes it to decline—and thus politicians can’t take credit for it or offer solutions.

But for all the head-scratching, there is one promising line of inquiry that’s only now beginning to see scholarly attention: the link between peoples’ health as children and their criminal activity as adults. Believe it or not, there’s been relatively little empirical work done to link childhood mental disorders and adult offenses. That’s changing. In November, The American Journal of Psychiatry published a study that asked whether “the national crisis in child community mental health services” contributes to “delinquency,” and whether more robust, timely responses to “youths with mental disorders” can reduce adult crime. The answers were “yes” on both points.

The study, carried out by researchers at Duke University, consisted of interviews with a cohort of 1,420 children aged 9 to 13 and a reassessment of these kids every year through the age of 16. During those years, the team identified those youths with mental health problems and diagnosed them. Everyone was tracked until 21 to identify arrests (criminal involvement is far more common between 16 and 20, and drops off sharply when people move into their twenties). The findings were telling.

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Julia Hallisy recently sent me her book, The Empowered Patient (PatientsafetyCA.org, 2008).  It is at once one of the most pragmatic and one of the most moving healthcare  books that I have ever read.

Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation. Kate died in 2000. She was eleven years old.

Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.

First she reminds us of the mind-boggling number of errors that occur in our hospitals every year. “As many as 95,000 people die annually” as a result of adverse events ranging from infections to fatal drug reactions.  It’s hard to grasp just how many people are dying until Hallisy gives us what she calls “a tragic reference point.” The number of lives lost to medical error is roughly equivalent to a World Trade Center attack occurring every two weeks during the year.    

Hallisy’s 300-page book is eminently readable, and filled with enormously useful detail. As she points out “the media and the government do try to warn us against the dangers we are up against with admonitions such as, ‘Make sure all your healthcare providers wash their hands before touching you,’ or  ‘Don’t sign blanket consent forms,’ or ‘Check your medication . . .’ 

“Good advice,” writes Hallisy, “but what exactly are you supposed to do to ensure that these things actually happen? Many of you reading this right now don’t know that you have a right to customize your consent form.”

I certainly didn’t.

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Last week, I wrote about the “cholesterol con,” the widespread belief that “bad Cholesterol” ( LDL cholesterol) is a major factor driving heart disease, and that cholesterol-lowering drugs like Lipitor and Crestor can protect us against fatal heart attacks. These drugs, which are called “statins,” are the most widely-prescribed pills in the history of human medicine. In 2007 world-wide sales totaled $33 billion. They are particularly popular in the U.S., where 18 million Americans take them.

We thought we knew how they worked. But last month, when Merck/Schering Plough finally released the dismal results of a clinical trial of Zetia, a cholesterol-lowering drug prescribed to about 1 million people, the medical world was stunned. Dr. Steven E. Nissen, chairman of cardiology at the Cleveland Clinic called the findings “shocking.”  It turns out that while Zetia does lower cholesterol levels, the study failed to show any measurable medical benefit.

This announcement caused both doctors and the mainstream media to take a second look at the received wisdom that “bad cholesterol” plays a major role in causing cardiac disease. A Business Week cover story asked the forbidden question, “Do Cholesterol Drugs Do Any Good?" 

The answer, says Dr. Jon Abramson, a clinical instructor at Harvard Medical School, and the author of  Overdosed America, is that “statins show a clear benefit for one group—people under 65 who have already had a heart attack or who have diabetes. But,” says Abramson,  “there are no studies to show that these drugs will protect  older patients  over 65—or younger patients who are not already suffering from diabetes or established heart disease –from  having a fatal heart attack. Nevertheless, 8 or 9 million patients who fall into this category continue to take the drugs, which means that they are exposed to the risks that come with taking statins –which can include severe muscle pain, memory loss, and sexual dysfunction.”

Finally—and here is the stunner—it turns out we don’t have any clear evidence that statins help the first group by lowering cholesterol levels.  It’s true that they do lower cholesterol, but many researchers are no longer convinced that this is what helps patients avoid a second heart attack. It now seems likely that they work by reducing inflammation. In other words, these very expensive drugs seem to do the same thing that aspirin does.  (Are they more effective than the humble aspirin? We’ll need head-to-head studies to find out.)

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In my last two posts, I touched on some pretty significant FDA-related developments—and even though they’re barely a week old, a lot has happened since my commentary. Here’s a look at where things stand now. It’s not pretty.

The FDA, Avastin, and Wall Street

In a post last week, I urged the FDA not to approve Avastin for use with breast cancer patients, because (1) the science shows it’s not effective enough to warrant approval and (2) giving it the okay would set a precedent for approving mediocre drugs..

Naturally, the FDA approved Avastin at the end of last week.

In a comment quoted by MarketWatch, analysts called the FDA’s decision “a welcome outcome” because "investors and companies have expressed growing concern that the FDA’s hurdle for approving drugs is a moving target and that a survival benefit is a necessity.”

But wait—just last week the Wall Street Journal noted that FDA “evaluation methods have remained largely unchanged over the last half-century.” In fact, the Journal cited this long-term consistency as emblematic of the agency’s “bureaucratic culture”—and yet here are the analysts, claiming that the problem is inconsistency.

Of course, the logic behind approval is a secondary concern to
investors—what really matters is the financial consequences of an FDA
decision. In this case the green light from the FDA sent Genentech
shares shooting up by almost 10 percent in a single day. Predictably,
financial analysts see big things in the company’s future: the
investment bank Cowen & Co. forecasets  a peak potential sales
estimate of $1.5 billion in 2012 and RBC Capital Markets analysts have
upped their 2008 and 2009 sales forecasts by $17 million and $30
million respectively (the drug’s 2007 sales already clocked in at a
whopping $2.7 billion).

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Since 9/11, one Army division has spent more time in Iraq than any other group of soldiers: the 10th Mountain Division, based at Fort Drum, New York.

Over the past 6 years and and six months, their 2nd Brigade Combat Team (BCT) has been the most deployed brigade in the army. As of this month, the brigade had completed its fourth tour of Iraq. All in all, the soldiers of BCT have spent 40 months in Iraq.

At what cost?  According to a February 13 report issued by the Veterans for America Wounded Warrior Outreach Program, it is not just their bodies that have been maimed and, in some cases, destroyed. Many of these soldiers are suffering from severe mental health problems that have led to suicide attempts as well as spousal abuse and  alcoholism.

Meanwhile, the soldiers of the 2nd BCT have been given too little time off in between deployments:
In one case they had only six months to mentally “re-set”  following an eight-month tour in Afghanistan–-before beginning a 12- month tour in Iraq.

Then, in April 2007, Secretary of Defense Robert Gates decided to extend Army tours in Iraq from 12 to 15 months—shortly after the BCT had passed what it assumed was its halfway mark in Iraq.

As the VFA report points out:  “Mental health experts have explained that ‘shifting the goalposts’ on a soldier’s deployment period greatly contributes to an increase in mental health problems.”

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