Hospitals

Last month, an essay posted by retired physician Ken Murray called “How Doctors Die” got a huge amount of attention, some negative but mostly positive. Murray tells the story of an orthopedic surgeon who, after being diagnosed with pancreatic cancer, chose not to undergo treatment. The surgeon died some months later at home, never having set foot inside a hospital again.

Shannon Brownlee's back at TIME Ideas with a new op-ed yesterday: this one about the article we mentioned last month, called How Doctors Die. Brownlee adds more context to the first commentary, by retired physician Ken Murray, with gut-wrenching descriptions of precisely why doctors tend to avoid intense, invasive care at the end of life:

"Doctors also know that undergoing heroic measures is a lousy way to die. They’ve seen what it’s like for an elderly patient to end up in the ICU, hooked up to machines, often semiparalyzed, in pain, lying on what philosopher Sidney Hook called “mattress graves” during his own terminal illness. At a recent meeting I attended, one emergency physician tearfully admitted she didn’t think she could stand to hear the sound of ribs breaking as she perform CPR on yet another elderly patient who almost certainly would not survive."

Brownlee also mentions Angelo Volandes, a physician who's working on a series of videos illustrating what it actually means to go through various heroic efforts at extending life. We think such an effort could be incredibly valuable to patients, and will help prevent a lot of unnecessary suffering, and we applaud the project.

Imagine you are sitting in first class on a plane, waiting for the plane to push off from the gate, when you see two people in uniform, the pilot and co-pilot, dash from the Jetway into the cockpit. A few seconds later, a voice comes over the intercom, saying, “This is Captain Jones, please be sure your seat belts are fastened. We’re ready for takeoff.” What crucial event could not have occurred in this scenario? The pilot and co-pilot did not go through their checklist of safety measures. Fuel tanks full? Check! Flaps up? Check!

If you ran a summer camp that never reported the vast majority of times that you hurt one of your campers, you'd probably be shut down, arrested, or worse. The situation would be similar if a restaurant repeatedly made customers sick, or if a skydiving business habitually gave people the wrong parachutes.

Why, then, do hospitals only report about one in seven of the hundreds of thousands of medical errors, infections, and other adverse events that harm patients every year? And why can they get away with it?

That's a crucial question posed by Shannon Brownlee's most recent piece on TIME Ideas: An American Hospital: The Most Dangerous Place? Brownlee addresses the recent report from the US Department of Health and Human Services, which catalogued problems with the reporting system for medical errors and other patient harm. She argues that the reporting problems are only a piece of a larger quality and safety problem, and that hospitals need to move quickly to adopt checklists and other types of safety mechanisms:

"Some hospitals have made great strides in reducing errors and infections using — you guessed it — checklists. About 10 years ago, Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins Hospital in Baltimore, and a team of colleagues put together a series of checklists for some of the most common procedures performed in the intensive-care unit. For example, they created a list of steps for how to put in a central line — a tube for delivering medication directly into a vein in the patient’s chest — in a way that reduced the risk of infection. They made a checklist to prevent patients on a ventilator, or breathing machine, from contracting pneumonia. When Pronovost was given a grant to get every ICU in the state of Michigan to use just three of his checklists, the result was 1,500 lives saved and the state of Michigan saved $100 million."

You can read the full story here: http://ideas.time.com/2012/01/09/american-hospitals-the-most-dangerous-place/

The most recent issue of the Archives of Internal Medicine includes a provocative survey of primary care physicians—one that indicates a significant, long-overdue change in how both providers and patients see medical care.

The study surveyed over 600 physicians by mail, and found that 42 percent believe their patients are getting too much medical care. That’s seven times as many as the six percent who believe their patients aren’t getting enough. Further pressing the case, about 30 percent of PCPs surveyed said that their own practice was more aggressive than they’d like.

Think about what this means. Four years ago, when the Health Policy Program’s director, Shannon Brownlee, published her book Overtreated, most Americans, and a lot of providers, legislators and policy experts thought the only real problem in U.S. healthcare was too little care – because nearly 1 in every 6 Americans was uninsured. Now we have a study that shows that physicians are well aware that overtreatment is also a problem

Implementing new health IT may decrease hospital mortality due to medication errors and uncoordinated care, but is the effect great enough to justify multimillion-dollar investments in new technology?  Maybe not, according to a new study from Health Affairs.

Spencer Jones and colleagues from the RAND Corporation looked at hospital outcomes data for Medicare patients from 2007 to see whether use of CPOE technology (Computerized Physician Order Entry) was associated with lower mortality for heart attack, heart failure, and pneumonia.  They looked at 4,644 general acute care hospitals, categorizing them by the percentage of orders written using CPOE.  There was a small reduction in mortality for heart attack and heart disease, but not pneumonia, associated with CPOE use – really small.

Based on the results, the authors predicted “complete uptake by hospitals of electronic medication ordering at levels comparable to the requirements of stage 1 meaningful use (at least 30 percent of orders written using CPOEs) could result in 1.2 percent fewer deaths of hospitalized Medicare beneficiaries from heart failure and heart attack,” but this result was not statistically significant.

Two weeks ago, a new study funded by the National Cancer Institute of the NIH released its findings: low-dose CT scanning to screen longtime smokers for lung cancer can reduce mortality by 20 percent relative to x-ray screening.*  That might seem like great news—if not for the reaction from hospitals and medical providers, which are using the study as an excuse to market CT scans.

The study received broad coverage when it was released, which isn't surprising—a 20 percent reduction in deaths among smokers is a pretty important result. However, the patients in the study were all longtime smokers between the ages of 55 and 74, with more than 30 pack years (meaning they smoked an average of a pack a day for 30 years, or two packs a day for 15 years—over 200,000 cigarettes in all). Since the study was so narrowly focused, it didn't establish that CT screening offered any benefit to younger smokers or those who hadn't smoked as long.

David Clark sat in an ambulance for hours late Saturday night in front of the Park Slope Armory in Brooklyn. Mr. Clark, who is 48 and relies on a wheelchair because of diabetes and a leg injury, was late to receive his medicines. But he still had not even been admitted to the armory, which was a designated shelter for patients with special medical needs who had been displaced because of the storm.

It might seem like the New Health Dialogue comes down pretty hard on "medical innovation" sometimes. Yes, we are skeptical of the "new" and the "high-tech" -- for example DiVinci robotic surgery or 64-slice CT scanning -- because there is often evidence that the newest invention is really only the most expensive, rather than the most efficacious.

Sometimes though, the latest advance in medical technology simply blows your mind and makes you want to stand up and applaud. That is surely the case with Charla Nash, the newest recipient of a full face transplant. Mauled by a chimpanzee in 2009, Ms. Nash's face was disfigured beyond all recognition.

A new study in the Journal the American College of Cardiology finds that doctors at different hospitals vary widely in their assessment of who qualifies as an appropriate candidate for elective coronary angiography (a way to look for clogged coronary arteries).  If Jack Wennberg and his daring band of disruptive Dartmouth Atlas docs have taught us anything, it’s that variation marks the spot for the inconsistent -- and often inappropriate -- use of health care services.

According to researchers at Duke University Medical Center, different hospitals use wildly disparate criteria for determining which patients need non-emergency coronary angiography.  The authors found that hospitals with a lower rate of positive tests -- meaning they test a lot of people who end up not having heart disease -- tend to be more likely to perform angiography on younger, asymptomatic patients. Out of more than half a million medical records examined, the researchers found some hospitals with rates of positive tests as low as 23 percent.