Where you are determines your end-of-life care
As you’ve likely noticed, the Dartmouth Atlas team has now focused its lens on end-of-life care and found, not surprisingly, what amounts to “more of the same.” Kaiser Health News’ Jordan Rau has the nuts and bolts, while Joanne Kenen, writing for Miller-McCune Magazine, takes a long view on the story, putting it into the context of popular Dartmouth Atlas pieces (think McAllen, Texas) and end-of-life outliers (La Crosse, Wis.). While you’ll have to check out her story for the in-depth version, here’s Kenen’s summary of the report:
Overall 1 in 3 of these patients died in the hospital, sometimes in the ICU and sometimes on life support, but there was significant variation from one region or even one hospital to another. Six percent of the patients received chemotherapy in the last two weeks of life, but in some regions and academic medical centers the rate went above 10 percent. Half got hospice but often for just a few days, too little for them and their families to fully benefit from the medical and psychosocial assistance and comfort hospice can offer.
If you’re looking for caveats, be sure to hit the second half of Rau’s story.
In addition to lives, checklists save money
Filed under: Health data, Health policy, Hot Health Headline, Studies
Last year, Atul Gawande and company made a splash by showing what a profound clinical impact checklists made on patient outcomes. Now they’re back, but this time the checklist evangelists are aiming for the pocket book. In the latest Health Affairs, Gawande and seven others contributed a paper with the descriptive title “Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality Of Care In U.S. Hospitals.”
Photo by cybrjoe via FlickrHere’s their arithmetic, courtesy of The Boston Globe’s Elizabeth Cooney
Time was the biggest cost in setting up the checklist, Gawande and his co-authors write in the journal Health Affairs. They estimated that a hospital with at least a 3 percent rate of complications per year would begin to see savings after five major complications were prevented. That means a hospital where 4,000 noncardiac operations were done each year could save about $25 on each procedure, or about $100,000 annually, they concluded.
As always, free access to Health Affairs studies is one of many perks enjoyed by AHCJ members.
Dissecting Gawande’s narrative structure
In a recent post, Not Exactly Rocket Science’s Ed Yong tried to break down Atul Gawande’s work and figure out why it can be so darn compelling. Yong and many thousands of others (myself included) were riveted by Gawande’s latest New Yorker piece, a treatise on palliative care.
Atul Gawande in action. Photo by Center for American Progress via Flickr.
It was a great read, but nothing shocking – much of it reminded me of sections of Gawande’s 2008 book, Better – and it clocked in at a mammoth 12,000 words. Yet, even in the age of bullet points and boldface, that didn’t stop anyone. Why?
Putting aside the fact that Gawande’s a wonderful writer who’s built a powerful brand for himself, Yong instead considered the power of Gawande’s narrative structure. It’s something I’ve noticed throughout the man’s work, and something that he can get away with as a prominent surgeon who writes for magazines: He saves the climax of his key anecdote (the patient’s outcome) for the end, and usually weaves it into several minor peaks and valleys in the course of the story.
These four sections are all obviously united by a common theme. But to hang together in a single feature, they need more than that. Gawande achieves this by using the tale of a terminally ill cancer patient, Sara Monopoli, to frame the four topics. It is obvious enough to use real-life stories to illustrate the theme of death and Gawande’s experience gives him plenty to draw from. But his critical move was to use a single story to frame all of the others.
Infection-reduction measures vs. the real world
The Wall Street Journal’s Katherine Hobson writes about the recent JAMA study which she says demonstrates that publicly reported infection control measures, including checklists, “don’t actually correlate with post-op infection rates.”
The study was designed to evaluate the six infection control measures tracked by the Surgical Care Improvement Project. Those measures include everything from antibiotics to hair removal and blood glucose levels.
None of those measures correlated with infection rates individually, Hobson writes, but when taken in aggregate things start to look a little better.
Study lead author Jonah Stulberg, a recent graduate of Case Western Reserve University School of Medicine (where the research was conducted) tells the Health Blog that the score is called an “all-or-none” composite, which is like a pass/fail: The hospital gets credit for a particular patient only if all the appropriate measures are taken.
With the statistics out of the way, Hobson addresses the biggest question: Why aren’t these prevention measures making a difference in the real world? The answer, as it always seems to be in these situations, is that life is complicated and human beings aren’t robots.
… there’s a big difference between a practice being proven to be effective in a clinical trial and then developing a measure that tries to estimate how often it’s done and then report it publicly.” Real life is messier, and factors such as surgical skill and hand-washing practices are tougher to measure.
Dale Bratzler, CEO of the Oklahoma Foundation for Medical Quality, tells the Health Blog the results don’t surprise him. Individual process of care measures for things such as heart attack and pneumonia also haven’t been shown to correlate with outcomes, he says.
Gawande, Google and health systems analysis
Filed under: Government, Health data, Health policy, Hospitals
Earlier this month, New Yorker writer and surgeon Atul Gawande brought his checklist gospel (video) to the President’s Council of Advisors on Science and Technology. Writing for AAAS’ science-policy blog ScienceInsider, Jeffrey Mervis chronicled the encounter, paying special attention to the observations of council member and Google CEO Eric Schmidt.
Google CEO Eric Schmidt. Photo by World Economic Forum via FlickrTo Schmidt, the challenge of creating a system that synthesizes patient history and creates a list of standardized recommendations boils down to a simple “platform database problem,” something he says computer scientists are very good at.
Gawande’s take is that programmers don’t quite understand the vagaries of a typical clinical encounter. The technological capability may exist, but it’s going to be hard to make an information system that is able to generate recommendations brief and practical enough to be of use to a typical super-busy physician who has to suss out six different problems in one 15-minute visit.
In the course of the discussion, Gawande and the council also bemoaned the relatively low status of the health systems analyst and brainstormed ways to raise the profile and effectiveness of the specialization.
Profile: Gawande’s self doubt gives writing nuance
Filed under: Health care reform, Health journalism
Harvard Magazine’s Elizabeth Gudrais looks at Dr. Atul Gawande’s Obama-approved work at the New Yorker and explores how and why a Massachusetts endocrine surgeon has become one of the most influential writers in today’s health care reform debate. Gudrais follows his writing career from his start at Slate.com to The New Yorker and the now-infamous town of McAllen, Texas, and examines how Gawande’s own “neurotic self-doubt” has helped his work hit the all the right chords in a nation going through its own period of health care soul-searching.
Gawande responds to critics of health cost piece
Filed under: Health care reform, Health data, Health policy
Atul Gawande, M.D., who recently wrote a much-discussed article about health care costs, has responded to his critics in a New Yorker blog post. He addresses the three main objections that have been raised about his article: the snowbirds, medical malpractice and the unhealthy population in McAllen, Texas. His rebuttal includes data about McAllen and El Paso, the two cities he used for comparison.
He also points out that McAllen and El Paso spend nearly the same amount of money on health care in the early nineteen-nineties. “By the late nineties, however, it had become one of the most expensive regions in the country for Medicare and it has continued that way. Yet, public data show no sudden decline in health status or income for the McAllen population.”
Two communities, two tales of health care costs
Filed under: Health care reform, Health data, Health policy
In The New Yorker, Atul Gawande, M.D., looks at how the United States can contain the rising cost of health care by examining the experiences of towns on both ends of the spending spectrum.
He first looks at McAllen, Texas, which he describes as “the most expensive town in the most expensive country for health care in the world.”
He found that McAllen has remarkably advanced health care technology but “there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country.”
Over dinner with six McAllen doctors, Gawande learned that one reason health care there is so expensive there is that doctors “were racking up charges with extra tests, services, and procedures.” He consulted an economist and looked at Medicare data to confirm that patients in McAllen get more abdominal ultrasounds, bone-density studies, stress tests and other procedures. Gawande also talked to hospital administrators who, like many people in their positions, were unaware of data showing that more costly treatment is not necessarily better treatment.
Gawande then looks at Grand Junction, Colo., which is one of the lowest-cost markets in the country that has achieved some of Medicare’s highest quality-of-care scores. He explains that the medical community there has agreed to “a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates.”
Other health systems have implemented similar approaches with similar results. Gawande describes the dichotomy of McAllen and Grand Junction as the “battle for the soul of American medicine.”
Study prompts hospital CEO to blog about change
A study led by Harvard researchers and published in the New England Journal of Medicine found that hospitals that used a safety checklist before, during and after surgery experienced fewer deaths and complications.
Atul Gawande, M.D., senior author of the paper and a surgeon at Brigham and Women’s Hospital, told The Boston Globe that the results were “beyond anything we expected.”
According to the Globe:
“The checklist is based on World Health Organization guidelines and takes only a couple of minutes to complete. It requires operating room staff to complete a series of verbal steps before giving the patient anesthesia, before the incision, and before the patient leaves the operating room.”
Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston, blogged about the study and says he is frustrated about the failures in the medical system to make changes “in a profession that is so steeped in the practice of giving individual physicians the prerogative to do their work the way they want to.”
Gawande is scheduled to speak Feb. 11 in a lecture that will be broadcast online as part of the NIH Director’s 2008-2009 Wednesday Afternoon Lecture Series. The topic of his lecture is “Ignorance vs. Ineptitude: Science and the Causes of Failure in Medicine.”
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