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Archive for June, 2007

Saturday, June 30th 2007

Getting Ready For First Day

Like A Chicken With Its Head Cut Off…Or Something

I start third year on Monday.

I knew I started with medicine, but until yesterday not where. I head on Monday to a military hospital. I’m actually looking forward to that. I’ve heard nothing but good things about going through there and I think it is something interesting to start with. I figure you’ll see a younger population and probably less of the same.

There is a little bump in the road, I only now know that I need my registration and inspection to be up to date in order to drive on base.

In a stunningly bad coincidence, my car’s inspection runs out at the end of this month (i.e. today). Trouble is, it is raining down here and I have a personal horror study of trying to get an inspection done while it’s raining. Long story, short: You can’t get it done (at least per the rules) because the slick pavement doesn’t allow effective testing of your car’s brakes.

It should dry up later today though. If not maybe I’ll be hitching a ride to my first day of my first rotation.

Saturday, June 30th 2007

More On Pay-for-Performance

The AMA will now “actively oppose” some private P4P measures.

[A]fter five hours of debate — often over the addition or deletion of a single word — the AMA’s House of Delegates said that it will “actively oppose” any pay-for-performance programs that do not meet the AMA’s five pay-for-performance principles.

Adopted in 2005, those principles specify that programs should ensure quality of care, foster the patient/physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.

The number of pay-for-performance programs, which provide monetary bonuses to participating physicians who make progress in achieving specific quality or efficiency benchmarks, has increased significantly over the last four years — from 35 plans in 2003, to 130, for a growth rate of 271%, according to one report. By 2008, it’s estimated that there will be more than 160 pay-for-performance programs covering services provided to an estimated 85 million patients.

But this is minutiae.

The association was already on record as opposing plans that didn’t meet AMA criteria, but, said Dr. Rohack, by adding the word “actively” the delegates authorized the AMA to mount opposition against any plan, anywhere that did not meet the standards.

I’m about as involved in organized medicine as any student can be. And while I couldn’t stay for the big HOD meeting at Annual this year (which is where this resolution came from), I’ve been around the pay-for-performance debate.

And I’m not sure this adds anything to it. The battle really is between those who don’t want physicians to have anything to do with planning P4P and those who think P4P is coming no matter what physicians do, and so we better get to the bargaining table to make its implementation more…acceptable.

There was near disaster in Las Vegas at the AMA interim meeting last year when Secretary Mike Leavitt stumbled into the P4P bear trap during a speech to the physician HOD. In it he basically admitted that P4P was coming no matter what, and it was coming so that payers (Medicare) could save money.

Kind’ve a no duh, but even as his handlers used a sheep herding hook to drag him off the stage the outrage was blooming amongst the physicians. I think the argument on how to respond to those comments by the HHS Secretary was the best display of the schism in organized medicine (and amongst all physicians) over how to respond to pay-for-performance initiatives.

I’m not sure this new resolution does much to gap the divide.

I’m on the record for thinking that, if implemented properly, P4P can actually be a positive thing; not just something physician’s have to get used to. But even if I didn’t think that, it seems to me that P4P is coming no matter what.

It is. That is just reality.

And while there’s something valiant in being principled, the greater part of such is discretion. Choose your battles; go to the table on pay-for-performance in order to assure that at least it has physician input.

And, through all my meetings, that has been the consistent position of the AMA it seems. They’re willing to go to the table, but once there to only acquiesce to P4P plans under certain terms (such as guidelines being drawn up by physicians). Throwing in the word active changes this position, how? It opens up more options for the BOT? Small, small change. I’m not sure how many of the nay sayers such can bring over to the side of ‘compromise’.

Friday, June 29th 2007

Shocking News: JAMA Jumps To Publish An Anti-P4P Study

That Medicare PMHQID program doesn’t have such amazing initial results. So says a JAMA study (H/T Kevin, MD).

Researchers looked at information from hospitals treating 105,383 patients over three years beginning in 2003. They evaluated such factors as whether the hospitals prescribed aspirin and widely accepted cardiac drugs called beta-blockers and ACE inhibitors, and whether patients were counseled to quit smoking.

Compliance rose to 94.2% from 87% at the pay-for-performance hospitals. At the others, compliance also rose, to 93.6% from 88%. Researchers found a “slightly higher rate of improvement for 2 of 6 targeted therapies” but concluded that “overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites.”

It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.

“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.

But seriously, this doesn’t tell us anything does it? This hospital program is counting on Medicare to punish hospitals and then hospitals to pass on the financial punishment to providers?

And as the study appears to admit, there’s a good chance there simply wasn’t enough incentive to promote…adequate change.

We All Know This Is Why P4P Is Coming

Pay-for-Performance is coming from CMS, in order to save some cash. But whatever their primary motives isn’t compensation being tied to performance – as long as it is implemented right – part of the same accountability and transparency physicians are calling for from all other players in the American health care system. I certainly know I think we need more transparency and accountability for payers and for pharma and others.

It isn’t like physicians are far and above better in those departments than insurance or drug companies. Let’s work towards it and some form of P4P can, and should, be part of that.

Just kidding about the JAMA thing.

Friday, June 29th 2007

Dr. Anna Pou

Away from New Orleans the memory of Katrina seems like it is already starting to fade. So you’re excused if you don’t remember the story of Dr. Anna Pou and co. who were accused of killing patients at Memorial in N.O. in order that they could you know…get out themself.

Despite the Coroner’s findings it is just short of a year since Dr. Pou was arrested and charged. Now it looks like the D.A. down there is really looking to string the Otolaryngologist up. There is immunity for nurses originally charged with Dr. Pou,

Two nurses accused in the post-Katrina deaths of four patients at New Orleans’ Memorial Medical Center have been offered immunity to testify before a special grand jury, sources close to the investigation tell CNN.

Sources close to the investigation told CNN the two nurses are expected to testify before the grand jury in the next two weeks, which could signal a possible wrapping up of the case. It could also signal the main target of the investigation is Pou, a physician who was under contract with Memorial Medical Center when Katrina struck.

I’ve been away from the blogosphere for a while, and I’m sure there’s been so chatter about this Grand Jury movement. Certainly Dr. Pou’s efforts have a strong internet presence. You can visit her defense fund page here.

Tuesday, June 19th 2007

Grand Rounds Grand Rounds!

Codeblog has Grand Rounds up for this week. Nearly forgot about it!

Monday, June 18th 2007

Why Do International Comparisons Peeve Me So?

It’s All The System’s Fault!

Before I go off on my little tangent I’d like to admit (as I always do) that the U.S. has one of them least efficient health care systems the world over. It fails to value prevention, it fails to control costs, it fails to identify evidence based procedures.

It also allows the freest choice for those who can afford it and single handedly drives biomedical and pharma innovation.

All that aside, as I’ve made it clear over the years it really annoys me when people throw the cost of health care in this country out there and then really imprecise measures of quality – such as life expectancy – and pass it off like this country isn’t getting value for what it spends. Here’s the LAT article (via THCB) which has required this post.

Amid stacks of reports, all with wonky measures of access, equity, efficiency and medical outcomes, two statistics stand out. The U.S. spends more on medical care than any other nation, and gets far less for it than many countries. According to the 2006 analysis by the Organization for Economic Cooperation and Development, the U.S. spends an annual $6,102 per person — more than any other country and more than twice the average of $2,571. Yet Americans have the 22nd highest life expectancy among those nations at 77.2 years compared with the analysis’ average of 77.8 years. People in Japan, the world leader in longevity, live an average of 81.8 years.

Talk about me almost blowing my top.

Look, we’re only talking about magnitude here because all can admit the “faults” of the American health care system. But the magnitude; the degree to which blame can be heaped on the system itself is important because of the level of outrage that is building. Personally, I think it is insulting that groups like the Commonwealth Fund think they have to stay on message and dumb down the findings and explanations for the general consumer.

Because while I admit the comparative shortcomings of the American healthcare system a lot of these numbers owe something to the way this country lives. Ignoring that fact; continually marching out really multivariable figures as evidence of this country’s shortcomings is annoying.

Plenty of our health woes are on us as patients, not on faults of the system.

Americans in general lead some of the unhealthiest lives in the western world. Rightly throwing out those Pacific Island nations America is the second fattest country in the world, it has some of the highest rates of diabetes in the world, it has a higher mortality per 1000 females due to cardiovascular disease than any nation you’ll see held up as a glorious example of health care done right.

Get out of Dodge if you think much of that can be put on access issues or on a failure of American medicine to promote disease prevention. Us stuffing Big Mac’s down our faces (and importantly doing it longer and at a greater rate than other countries) isn’t a public health failure. That is a societal problem.

The best evidence says Americans are sicker than their Canadian counterparts, sicker than their British counterparts, independent of their access to care or the quality of care they receive.

Read More »

Saturday, June 16th 2007

Ethical Trauma Research?

This is ambitious, as WaPo describes it.

The federal government is undertaking the most ambitious set of studies ever mounted under a controversial arrangement that allows researchers to conduct some kinds of medical experiments without first getting the patients’ permission.

The $50 million, five-year project, which will involve more than 20,000 patients in 11 sites in the United States and Canada, is designed to improve treatment after car accidents, shootings, cardiac arrest and other emergencies.

About 40,000 such patients show up at hospitals each year, and the standard practice is to give them saline infusions to stabilize their blood pressure. For the study, emergency medical workers are randomly infusing some patients with “hypertonic” solutions containing much higher levels of sodium, with or without a drug called dextran. Animal research and small studies involving people have indicated that hypertonic solutions could save more lives and minimize brain damage.

You don’t give give your consent for standard of care procedures in these kind’ve trauma situations anyway. How far do trauma care practices have to be vetted for research like this to be run?

Before starting the research at each site, researchers complete a “community consultation” process. Local organizers try to notify the public about the study and gauge the reaction through public meetings, telephone surveys, Internet postings and advertisements and through stories in local media. Anyone who objects can get a special bracelet to alert medical workers that they refuse to participate.

Trauma research like this has sparked interest before. We all remember some of these blood substitutes over the past several decades. Personally I think, just from this short story, these studies seem pretty within bounds.

Saturday, June 16th 2007

Now You Know Who To Hit Up For A Living Donor Organ

Just a weird story from Kevin, MD wherein a patient doesn’t get a kidney because the unrelated donor might have been coerced into donation by a cult. Here’s the Toronto Globe & Mail story,

Kate and Nick Croft, Falkingham’s mother and stepfather, allege that the leader of the Jesus Christians, David McKay, coerces his followers into donating kidneys in an effort to garner media attention. The couple said they sent several e-mails to the Ontario Ministry of Health and Toronto General, pleading with them not to go through with the transplant, arguing that their son was not acting under his own free will. A spokesman for the Ontario Ministry of Health declined to comment, citing privacy concerns.

[The potential recipient] Sabloff summarily dismisses the Crofts’ brainwashing allegations. She said Falkingham was acting under his own free will and was only following his heart.

Here’s the Jesus Christians own webpage and the Wikipedia write up on the cult.

Friday, June 15th 2007

Smoking On The Way To The OR

Let’s Hope Barney Never Needs A New Hip

The NHS reiterates – if you keep smoking, it’s going to take you longer to get that surgery.

The ruling applies to routine operations such as hip replacements and heart surgery for conditions that are not immediately life-threatening.

If smokers refuse to give up, they are still likely to be treated but may have to wait longer.

Leicester City Primary Care Trust will become the first health authority to introduce the “quit or wait” rule this summer. Other health trusts are consulting on the idea.

Rod Moore, the trust’s assistant director of public health, said: “If people give up smoking prior to planned operations it will improve their recovery. It would reduce heart and lung complications and wounds would heal faster.

“Our purpose is not to deny patients access to operations but to see if the outcomes can be improved.”

However patients’ groups argue that the move is about the NHS saving money rather than improving patient care.

You think Sherlock?

Seriously I wouldn’t have a problem with this if socialized medicine in the UK wasn’t surprising private options. Then they could just refuse to quit and have a legitimate avenue of paying for the operation themselves. But as it stands right now, this is only another example of the access to care issues raised by health care systems with bureaucraticly managed global budgets.

Friday, June 15th 2007

More Controversy For The Administration

President Bush has nominated Dr. James Holsinger for Surgeon General. He appears more than qualified with his public and academic service.

Holsinger served as Kentucky’s health secretary and chancellor of the University of Kentucky’s medical center. He taught at several medical schools and spent more than three decades in the Army Reserve, retiring in 1993 as a major general.

But his position on homosexuality, especially voiced in roles in service to his church, is drawing much ire. In 1991 for a committee of the United Methodist Church, Dr. Holsinger published “The Pathophysiology of Male Homosexuality.”

I guess the question is: Do these views really speak to his ability in this job considering their age and the context in which they have been made? At the least the entire thing is a mess and unfortunate, considering the acting Surgeon General was such a friendly, easy going, competent guy when I met him last year. Sad to pass over Dr. Moritsugu for this big stinking mess.