The Mayo Clinic is a leader in dealing with opioid-addicted physicians, nurses, and technicians and the risk they present to patient safety.
This article was originally published on June 12, 2014.
The Mayo Clinic, is rigorous about preventing opioid-addicted workers from stealing injectable drugs and putting patients at risk. It may be more relentless in its efforts than any other healthcare organization in the country.
That's because it has encountered the problem so often—at least 40 times in the last five years, says Keith Berge, MD, a Mayo anesthesiologist who chairs the clinic's Medication Diversion Prevention Committee and heads the Minnesota Board of Medical Practice.
Knowing that opioid-addicted clinicians are out there, the Mayo, with 59,000 employees in five states, now looks harder than ever to find them.
The focus on healthcare worker diversion started 15 years ago, Berge tells me. That's when the clinic realized it was sending at least one anesthesia worker a year into treatment for fentanyl addiction, one of the drugs to which that specialty has easy access.
Then in 2008, the clinic discovered that a catheterization lab nurse at Mayo's hospital in Mankato, MN was stealing patients' fentanyl, using the syringe on herself, then replacing it with saline for use on the patient "so cath lab patients were getting no sedation for their procedures," Berge says.
"It ended up being on the front page of the Minneapolis Star Tribune, and caused a lot of angst at the highest levels. People suddenly realized, 'Jesus, this is a very scary problem. We need to make it stop.' "
Fortunately, no patients had been infected. Yet.
So the Mayo created D-Dirt, the Drug Diversion Intervention and Response Team led by a special diversion coordinator. The team developed policies for various units. The prevention and detection ball started to roll.
Just Make This Stop
The bomb dropped, in 2010. It was every hospital's worst nightmare.
Here's what Berge says happens at the Mayo now, and what he believes every hospital in the country should consider implementing to avoid controlled substance abusers among their workers:
1. Have a zero tolerance policy for theft of any drugs from anywhere. And have a zero tolerance policy for any worker who fails to properly witness a coworker disposing a drug that is not ultimately given to the patient.
Make sure workers know the hospital considers this so serious, that they will lose their jobs and be reported to the appropriate authorities. Emphasize that this behavior puts patients in danger.
Have a pre-employment drug screening program and an education campaign that stresses trying fentanyl or another opioid out of curiosity, even one time, is not safe. "People say I'll just try it once. But fentanyl is so profoundly addictive that's it. It's over," Berge says. "I say it's like they found the orgasm button and they can push it every day, all day long."
2. Make friends with law enforcement agencies, such as local police or U.S. Drug Enforcement officials, who can process search warrants of employees' homes and cars to help prove a case. This helps put the case on the record so prospective employers can be warned.
3. Employ a 24-hour diversion hotline for workers to report suspicious behavior. Advertise the program with a slogan such as "Save Your Co-worker's Life," which the Mayo posts on its Pyxis machines.
Staff the hotline with qualified personnel and resources to enable prompt response to tips or concerns. Make sure that responders have authority to take prompt and appropriate action.
"The point that we hammer on is not that you are ratting out your colleague, but that this puts our patients in terrible danger, and your colleague in danger of losing their life," Berge says.
4. Assemble a team like the Mayo's D-DIRT. This includes a full-time Medication Diversion Prevention Coordinator, who is either a pharmacist or a certified pharmacy technician. The coordinator conducts educational campaigns, supervises D-DIRT activities, and helps investigate case reports.
5. Employ a waste retrieval system everywhere injectable opioids are used in patient care. This entails enforcing a strict policy that quantities of all drugs drawn that aren't used on patients be securely returned to a Class 2 controlled substances vault in the pharmacy, under the watch of cameras, for reconciliation with both the Pyxis and anesthesia records. This process checks that what's returned squares with what was drawn and what was given to the patient.
Randomly test drugs retrieved to make sure they are the real drugs. "People often inject syringes in the bathroom stalls, and so it is just as likely the syringe is filled with toilet water, because that's the water they have available to them when they're injecting," Berge says.
Start with the high-risk areas, such as the operating room suite, then recovery room, the emergency department, GI endoscopy, interventional radiology and cardiology. Consider adding other areas throughout the hospital and outpatient settings as resources permit.
Berge acknowledges that such systems are labor-intensive, logistically cumbersome, costly, and create another possible avenue for diversion among those charged with returning the drugs.
But everywhere the clinic has implemented such a system, "to our utter, jaw-dropping amazement, it has almost stopped diversion completely." While not foolproof, he says, "it somehow creates a mental barrier in peoples' minds that 'if I do this I'll get caught.'"
6. Throw out assumptions about healthcare workers who divert drugs:
• They are easily noticed because of their odd behaviors. They are not, and they are skilled at hiding their activity. They are often the best workers who come in early, stay late, and volunteer to do extra work.
• They are rarely discovered in regions with low opioid use. Wrong. Diversion happens everywhere there are healthcare workers. Especially where there are healthcare workers, because that's where the drugs are. Minnesota for example, has one of the lowest rates of opioid overdose in the nation, but in Rochester, there are a lot more healthcare workers per capita than the rest of the state.
• Only workers with access to drugs divert them. Not true. While it's mostly nurses who divert drugs because their numbers are so large, people in every job description in the Mayo system have been caught diverting drugs, from janitors to nurses to physicians, even a toxicology lab tech who, as he tested the fentanyl for evidence of diversion, was caught diverting.
None of the major incidents nationally in recent years, which required notification and testing of 30,000 patients, involved workers whose job description gave them access to controlled substances.
Berge says that a hospital executive has not yet been caught, "but it will happen." The Mayo has even had several healthcare workers caught diverting drugs while they were patients in the hospital.
7. Know and keep track of areas throughout your organization that are the most vulnerable, from the loading dock to the incinerator and update them when new diversion schemes are detected.
8. Report it. Have a policy that when an employee is found to be diverting drugs, the hospital has an obligation to report that to the DEA, as federal law requires. The hospital also should report to the responsible state professional licensing board or hospital licensing agency, and if the diverter is a physician or dentist, to the National Practitioner Data Bank.
9. Make sure hospital leaders understand that as healthcare systems get better at creating barriers to theft of controlled substances where they are stored, the theft that does occur will happen closer and closer to patient care, at the bedside, "at the stopcock of the IV."
Berge says that today, it's harder for an addicted healthcare worker to steal oxycodone from a hospital pharmacy, because of newer policies that secure and account for it. So don't be surprised if they are more successful wherever the drugs are used.
10. Offer treatment once an employee is caught and terminated. Even extend healthcare benefits that provide coverage. "We say, 'You're fired. Now how can we help you.'?"
While the Mayo may have an aggressive prevention program, however it still finds problems because, perhaps, it is just looking harder to find them.
Just last week, Berge says, he got another call from a nurse in tears. It had happened again. That nurse had taken a vial of fentanyl and syringe out of the Pyxis for a patient and handed them to a second nurse who eagerly volunteered to draw it up and administer it.
But the first nurse saw that the syringe inserted wasn't the same one that she had handed the second nurse. D-DIRT was called and the syringe returned to the toxicology lab for its contents to be tested
"It wasn't fentanyl," he sighed.
"These people are very good at covering their tracks. They're hard to catch. And I think that's the message we're trying to get out. It's terrifying, but you have to look for it."
Medicare's wellness codes were launched with great fanfare, but despite the potential largess for primary care, physicians have been slow to submit claims, data shows. From MedPage Today.
A huge victory in primary care doctors' quest for better Medicare payment came Jan. 1, 2011, or so they hoped.
That's when six pages of the Patient Protection and Affordable Care Act kicked in, authorizing three novel billing codes so that as many as 33 million beneficiaries enrolled in Medicare Part B could receive "annual wellness" visits to help them thwart disease. Nationally, the amounts are significant, paying from $118 to $174 for each code, and possibly more in some locations.
That's billions of dollars worth of care physicians couldn't bill before. It pays not for dealing with patients' symptoms but for reviewing their screening tests and immunizations, family history, cognitive and physical abilities, risk for falls, and for designing a "personalized prevention plan" for every beneficiary.
It is, said, Reid Blackwelder, MD, board chairman of the American Academy of Family Physicians, a time "for patients and doctors to take a breath, and focus on looking ahead at risks they need to be aware of. It's a different mindset about care."
Better still, there's no 20% co-payment required as in normal Part B services.
Doctors already provided some of this care, but often in a choppy, haphazard way, squeezing admonitions about extra pounds, smoking, or alcohol use during other office visits.
But despite this potential largess for primary care, physicians have been slow to submit claims. For the third year of the new codes, only 12% of eligible beneficiaries had Medicare billings for these services, according to 2013 data from the Centers for Medicare and Medicaid Services.
"There's a lot of money and services being left on the table because of the way Medicare has structured this," said Joseph Scherger, MD, vice president for primary care at Eisenhower Medical Center, a 48-physician practice in Rancho Mirage, Calif., that struggled to make the codes work for them.
"That's because these visits are different and separate, instead of being integrated into the flow of care. Now, there's this awkward separatism that offices have to work around. Patients want to talk about their medical problems, but that ends up violating the intent of wellness visit," Scherger said.
The reasons doctors give for the poor uptake are many. Peter Lipson, MD, an internist in Southfield, Mich., who blogged about his concerns in Forbes in October, explained that when patients take time to see a doctor, they "expect they'll be able to tell him or her about their gout or sore arm."
"When patients start to do that, you have to redirect them. You have to say horrible things to them like, 'We can't talk about your arm right now. I know it hurts but you'll have to come back to talk about that.'"
"That's always a problem with patients," said Philip Webb, MD, a family physician in Ranger, Texas. "Just as you're walking out the door, they'll say 'Oh doctor, I have this chest pain.' And now you have to stop and address that."
Even with non-emergent complaints, Webb said he tries to manage those then and there, at the end of the wellness visit, "depending on my schedule, and how far behind I am that day." But usually, he doesn't have time, and just says, "I'll be happy to talk with you about that during another visit."
Some doctors find that problematic and don't bother billing these wellness codes because of the confusion and scheduling problems they can cause, even occasionally annoying and angering the patients. Or, they combine them with regular evaluation and management visits that can take nearly an hour.
"To say to a patient, 'I'm sorry, I can't talk about that' -- I can't do that to my patients," said Paul Speckart, MD, an internist in San Diego. "Their daughter takes the day off to drive them -- and they expect everything to be addressed."
Though he believes Medicare's new preventive care codes "are good medicine all around," Speckart said his practice combines the wellness exam "with the elements of the good old yearly physical," because patients shouldn't have to, and often won't, come back for a second, separate exam. While the new Medicare codes "look good on paper, they don't work out in practice" when services are separated this way.
Scherger said his practice has started to turn over the wellness visit to the "lead nurse who does all the intake and gets the targeted history, and goes over all prevention care and immunizations." The physician sees the patient briefly and just at the very end.
"It's kind of like when you get your teeth cleaned by a dental hygienist, and the dentist comes in to take a look at your mouth before you leave. You really have to treat it that way medically if you want to make this work."
If the patient raises a critical problem then, the doctor may reassess, asking "how bad are you right now? Let's get your medical visit scheduled right away," maybe later that afternoon or the next day.
If the doctor can review the new complaint the same day, the practice can add a second visit service to the wellness visit claim with a modifier that enables payment for both, explained Barbie Hays, coding and compliance strategist for the American Academy of Family Physicians.
But the modifier pays less than a separate evaluation and management service visit would. In addition, the physician usually schedules just 10 to 20 minutes for the wellness visit, while a new symptom complaint can take 30 to 45 or longer to evaluate.
Though it has taken a few years to get started, Webb and some other doctors are learning to love the new wellness codes. Webb said they help him "feel better about spending extra time with patients to discuss all these extras, like have you had your colonoscopy and your bone density tests."
Likewise for Michael Richter, MD, an internist in Rego Park, N.Y., who started billing the codes three years ago. "I think it's good for the patient, helps to screen for things that end up causing problems like depression, falls, dementia, and gets advance directives in the record. These are all very valuable things, and ultimately save healthcare dollars."
But these visits are not typical "physicals," or head-to-toe exams, which is what many patients expect when they come to the doctor, and what the physician is used to providing, although some have questioned their benefit in otherwise healthy patients. The patients usually do not even undress.
Not getting a "physical" confuses some patients, and requires time for physicians and their office staffs to explain -- often to uncomprehending 90-year-olds -- what the wellness visit is, and what it isn't, several physicians acknowledged. In fact, as CMS policies clearly say, Medicare never covers "routine physicals."
"That's where there needs to be communication at the front office and scheduling level as to what kind of visit patients are actually wanting, because Medicare does not cover physicals," said Hays. Patients also need to be informed what is a preventive exam, which they do and don't co-pay for, and what is a routine exam, including ordering of lab tests. "We all know we're dealing with elderly patients who aren't always familiar with their benefits," Hays said.
Robert Ostrander, MD, a family practice physician in Rushville, N.Y., said Medicare "made a paradigm shift, but ... made no effort to clarify that it wasn't a physical when they said they were offering this wonderful annual wellness service."
So Ostrander's practice took it upon itself to produce an explanatory letter to beneficiaries. The office also combines the wellness piece and the regular chronic disease management visit, "and anything else the patients want to address." That means patients will get billed a co-pay for the non-wellness part of the visit, and some "do gripe, because people want stuff for free. But most of my patients realize that primary care is woefully underpaid."
Some of Medicare's requirements are silly, Ostrander said. "It's moronic to discuss fall risk and watch someone walk across the room who was in the woods the day before splitting firewood. I don't need to do that screen. But for the wellness visit, Medicare says I do."
But overall, the codes have really been a good thing so far, Ostrander said. The visits have revealed problems he wasn't aware of, like a patient's depression that went unnoticed during regular complaint visits. "I was doing these things before, but for free. And for a lot of doctors it wasn't getting done at all."
Low uptake of the codes is a problem, acknowledged Blackwelder. And doctors need to be educated about "a culture shift" from what doctors are used to providing, which he termed "volume hamster-wheel medicine. It's a way for them to say to the patient 'you don't have to be sick to see me.'"
"And that's a very big difference. In fact I want to keep you from being sick, so let's set up time to look at your behavior, your lifestyle, and your end of life planning, these things that aren't addressed when you're trying to cram everything into one visit."
The burden now is on physicians to explain this to patients in a better way, and be more proactive, which the AAFP is trying to do for its members, "because obviously these codes have been around for awhile and we're not using them," Blackwelder said.
But Medicare should share more responsibility as well, Blackwelder said: "It needs to figure out the best way to communicate with patients" to let them know the value of these new codes, and that they too should request these visits from their doctors.
New federal regulations mean hospitals must count vaccination rates for anyone who works in a healthcare facility between October 1 and March 31.
This article appears in the July/August 2015 issue of HealthLeaders magazine.
At Lourdes Health System's two hospitals in New Jersey, ensuring that 2,700 workers get their seasonal flu shots—to stay healthy and avoid infecting patients—is such a high priority, that workers who refuse must find work elsewhere.
"We made it mandatory in the fall of 2012," long before many other hospitals in the nation, says Jennifer Moughan, chief human resources officer for the 325-licensed-bed Our Lady of Lourdes Medical Center in Camden and 173-bed Lourdes Medical Center of Burlington County in Willingboro.
Of course, "there were people, and challenges, and we had to work through those," Moughan says. And yes, "a few people were terminated for not getting their shots."
Jennifer Moughan
That's one reason Lourdes dramatically bucks a troublesome trend in New Jersey, where hospitals' average rates of influenza immunization have tracked the lowest in the nation. For the 2013–2014 season that ended March 31, 2014, only 59% of healthcare workers in New Jersey hospitals who should get their shots did so. Across the country, healthcare worker compliance rates averaged 79%.
Lourdes' two hospitals did far better. Their healthcare worker vaccination rates that season were 95% and 96%, respectively. Only a "handful" of eligible employees requested and qualified for legitimate medical or religious exemption, for which the system requires strict documentation, Moughan says.
Hospitals must count vaccination rates for anyone who works for any part of one day in the healthcare facility between October 1 and March 31. That includes everyone from volunteers and clerical workers to doctors and executives. Organizations then report their rates to the Centers for Disease Control and Prevention's National Healthcare Safety Network for public reporting, which began late last year for 2013–2014, on Hospital Compare.
Workers also must show documentation if they get their shots somewhere other than Lourdes, although Lourdes, like most hospitals, offers them to employees at no charge.
"You can't just tell us you got it at Rite Aid; I want to see that documentation," Moughan says.
With a goal of getting most workers immunized by December 15, when holiday festivities and travel enable viral spread, Moughan's teams "go floor to floor. We have stationary clinics and carts that roll around at night and on weekends, and there's no way you don't have a vaccine offered to you sometime in this period."
And those teams keep watch for procrastinators. "We're constantly looking at our data to see who's still out there not vaccinated." Leadership steps in to make the point. As soon as the vaccine arrives, Alfred Sacchetti, MD, vice chair of the department of emergency medicine, gathers up his staff in the hospital ED. He challenges a student nurse to "give him his shot, and he's always the first in line," Moughan says. "He's quite a character."
"It's not rocket science," says Alan Pope, MD, vice president of medical affairs and chief medical officer for Lourdes Health. "We don't want workers bringing flu to patients in our hospitals; patients have weakened immune systems or diseases that are prone to serious morbidity—in some cases mortality—if they get the flu. And we know it's important for us to have an intact workforce at the height of flu season."
Alfred Sacchetti, MD
The system accomplishes this through its education campaign to dispel myths and correct false information, such as the mistaken beliefs that the vaccine formula still contains mercury or that shots can transmit the flu.
Peer pressure, too, is used through distribution of "I got my flu shot" stickers. "You go into a meeting and see everyone around a table wearing a sticker, and you'd say, 'Oh, I better get mine.' " Moughan says. "They've been the biggest hit. You'd think, these are adults, and yet there they are, taking time and talking about how they pick out which one to wear."
But in northern New Jersey, another major hospital system struggles with a healthcare worker culture that has resisted vaccination, with only 45% of its 7,600 workers getting their shots in the 2013–2014 season.
"I don't know if we have a higher number of skeptics," says Suzanne Gallagher, administrative director for the Center for Occupational Medicine at the 750-licensed-bed Hackensack University Medical Center, "but the flu vaccine is always a hard sell and this last season, all the more so. Some said, 'It's just not that effective. Why should I bother?'
"We recently had The Joint Commission here," Gallagher says, "and they looked right at me and said, 'What are you doing to increase these rates?' "
So Hackensack UMC has begun to beef up its effort. It has launched what it calls a mandatory attestation requirement that surveys each employee who did not receive the vaccine to learn what their concerns were, Gallagher says.
"They said things like, 'I'm afraid it will make me sick' or 'I don't believe in it.' " A surprising response came from about 200 workers, many of them nurses who routinely give injections, "that they were afraid of needles." An educational program is being planned for this fall to improve employees' understanding of the science and safety of the vaccines.
Then the hospital will get really serious, moving to a mandatory program "for the entire healthcare team," says Lisa Tank, MD, Hackensack UMC's chief of geriatrics. "And if they're exempt, they'll be requested to wear masks in all patient areas." For all physicians, it will be absolutely mandatory.
Gallagher says the flu vaccine committee is exploring the idea of using incentives for employees who comply, similar to incentives in wellness programs.
Why New Jersey has the country's lowest vaccination rates is a mystery, says Kerry McKean Kelly, vice president of communications and member services for the New Jersey Hospital Association, which represents 72 acute care facilities. The fact that almost all facilities have relied on voluntary programs so far, may be part of the reason.
Ruth Ann Morris, RN, MSN, NEA-BC
"Clearly, we're not satisfied," Kelly says, adding that "our hospitals are now focusing more attention than ever on this issue" with many organizations moving toward a mandatory requirement for all employees who have patient care responsibilities.
Back on the other end of the spectrum, 355-bed Indiana University Health in Bloomington, which has 3,430 employees, achieved a 99.5% immunization rate in the 2013–2014 flu season, which was rounded to 100% on Hospital Compare.
"It's been a multiyear journey," with two policy changes that tightened restrictions to raise immunization rates from 50%, where they were in the 1990s, to 75% in 2013, says Ruth Ann Morris, RN, MSN, NEA-BC, vice president of patient care and chief nursing officer.
"An important part of what we did was educate our employees that this is about patient safety, and even if the employee does not become ill with the flu, they may pass the flu on to one of our patients who may have a different experience with influenza," she says. Another aspect is how strict the organization is regarding religious or personal belief exemptions, requests for which are reviewed by a panel of ethicists and chaplains.
Medical exemptions are granted sparingly by medical experts, too. Exceptions are made if a staff member has a severe allergy to eggs or an autoimmune disease, or if he or she has had a life-threatening reaction to the vaccine in the past. "Saying things like 'I'm afraid of shots' or 'I'll get the flu if I take the shot' are not acceptable." Now, she says, they receive far fewer requests for exemptions than when the policy first changed.
The programs work smoothly because of the speed with which the immunization campaign swarms the hospital's care teams. "What makes a difference is that we start in September and we're done in October," she says.
Megan Lindley
A prevailing controversy deals with the lack of the rock-solid evidence of causal links between healthcare worker immunization and reduced hospital-acquired influenza illness or mortality in patients, says Megan Lindley, the CDC's subject matter expert on healthcare worker vaccination.
That's because many illnesses look like influenza but are something else, and because it's extremely difficult to restrict patients' exposure to visitors.
"The strongest evidence for effectiveness would be a randomized controlled trial, but then you'd have to withhold [from some workers] a vaccine we know is effective ... and that would be unethical."
So the CDC tries to look across the nation at what seems to work. "Facilities that offer vaccination to their personnel, on site, at no cost, on multiple days and shifts, and have active programs promoting it have higher healthcare worker vaccination rates," Lindley says.
Still, there are issues. In a CDC Internet survey of healthcare workers who said they would not be vaccinated in November 2014, 20.8% said the vaccine doesn't work, 16.6% said they didn't need it, 13.3% said they might get sick from it, and 6.5% thought the ingredients "are not good for you. "
According to the CDC's Influenza Division, last season's vaccine was a tough one for influencing a national vaccination policy; it was only 19% effective against the prevailing virus, which meant that workers lost confidence in the vaccine's effectiveness.
Palomar Health, a two-hospital system in San Diego County with 395 licensed beds, converted to a mandatory mask requirement for any employees among its 2,754 workers who refused to get vaccinated last flu season. The result: Immunization rates soared, from 73% and 74%, respectively, during the 2013–2014 flu season year, to 90.7% and 93.5%, says Russell Riehl, director of employee, corporate, and retail health. That improvement will be posted later this year on Hospital Compare.
"You can decline the flu vaccine for any reason: medical, religious, or 'just because,' and that's fine. But then during flu season you'll have to wear a surgical mask from the time you enter the building until you leave, except when on break or in the cafeteria," says Valerie Martinez, system director of quality patient safety and infection control. That cuts out the hassle of securing documentation for patients who have a medical or religious reason.
Immunized workers are distinguished from those who must wear a mask by an annual flu shot sticker placed on their badges. The policy starts about four weeks after vaccine distribution begins in the hospital, and when mask dispensers are set up at every doorway for arriving workers.
"When we did that, those people who didn't like needles, or thought they had egg allergies, or said, 'Oh, it got me sick once before' had to wear the mask. And what happened is, they wore it for about a month, found it uncomfortable, and ultimately got the vaccine," Martinez says.
Palomar Health, however does not try to incentivize its workers with stickers or money. "It sends the wrong message," Riehl says. "We're here to take care of people, and to pay to incentivize an employee to ensure they don't pass an illness to a patient—well, you're setting a precedent that would not be good going down the road for many other situations."
Healthcare worker immunization rates now are reported to CDC and the Centers for Medicare & Medicaid Services as part of the inpatient quality reporting program, for which hospitals receive a 2% Medicare payment increase. But the measure is not yet part of hospital value-based purchasing or the hospital-acquired condition penalty, although it could roll in at some point.
Lourdes' Pope says that's a good idea. "I think our infection prevention staff would advocate for it," he says. "We think it's saving lives and preventing serious illness. And if it requires guidance by the regulatory agencies for that to occur, they should seriously consider it.
"You can see from what happened at our hospital in Camden, it's not at all hard to do."
Reprint HLR0815-8
This article appears in the July/August 2015 issue of HealthLeaders magazine.
Interest in using a variety of staffing and nursing engagement surveys as a reportable quality indicator is growing.
This article first appeared in the June 2015 issue of HealthLeaders magazine.
Do your hospital's nurses feel empowered? Are nurses' relationships with physicians strong enough that nurses can call out errors or ask questions without fear? Do they think their hospital hires enough nurses with appropriate skills and provides enough resources to provide safe and timely care? Are nurses involved in making policy?
When nurses are surveyed on these and related questions, which they increasingly are, poor scores may indicate troublesome systemic issues that could, directly or indirectly, affect quality of care, even adverse events. A drop in scores can often be tracked down to a specific hospital unit, research has shown. And poor scores may correlate to "nursing sensitive" patient outcomes, such as patient falls, lengths of stay, pressure ulcers, and infections.
Simply put, this measure is asking nurses what they think about the organization for which they work and how well they trust the care they deliver in their work environments.
Hospitals have learned the hard way how devastating drug diversion can be—not just to their reputations, but to their patients and their bottom lines as well.
This article appears in the January/February 2015 issue of HealthLeaders magazine.
For any executive who still thinks healthcare workers don't pilfer opioid drugs from syringes and cabinets, and would never put patients at risk, a growing number of health system leaders now beg to differ. They've seen it wreak havoc on their organizations.
From Minneapolis to Denver to Jacksonville to El Paso, hospitals have learned the hard way how devastating drug diversion can be—not just to their reputations, but to their patients and their bottom lines as well.
Thomas Sherman, MD, a gastroenterologist with a practice in Exeter, New Hampshire, has seen it firsthand five times in his 20-year career, in some cases catching coworkers—doctors and nurses—red-handed.
In the latest and most widely publicized instance, he'd been employed with a group practice for just over a year when he and another gastroenterologist noticed an odd occurrence.
Each had just seen a different patient with jaundice from a recently acquired hepatitis C infection, which rarely manifests with symptoms in the acute phase. It was, he admits, "something I'd not seen before."
"We were sitting in the office one evening saying, 'How is it that we have two patients with acute hep C?' So we looked for common threads." A quick chart review revealed that in recent months, both patients had undergone catheterization at 100-bed Exeter Hospital. "We contacted the administration the next morning, first thing, and the rest of the cascade moved very quickly."
In the ensuing months of 2012, public health and hospital officials in multiple states uncovered what was previously considered unthinkable. David Kwiatkowski, a hepatitis C–infected lab technician, had stolen syringes containing fentanyl that were intended for patients. Federal documents say that Kwiatkowski, who is now serving 39 years in prison, injected himself and refilled the same syringes—which now contained particles of his infected blood—and then replaced them for patient use.
That resulted in viral transmission to not just 32 cath lab patients at Exeter, but to another 13 patients who had received care in hospitals in Maryland and Kansas, where the technician had previously worked. Of the 45 patients, two have died. One, a retiree from the Boston division of the Office of Inspector General, underwent a leg amputation and another suffered liver failure.
Exeter, and some 16 hospitals in seven other states where Kwiatkowski worked, had to identify, contact, and test thousands of patients who were potentially exposed, including nearly 4,000 patients at Exeter.
Kwiatkowski was stopped at Exeter because it is a small hospital, and "the bulk of the liver disease cases came through our office," Sherman says. If the technician's next stop had been at a larger organization, his trail of infections might still be unknown, Sherman says. Patients infected with hepatitis C can take years to manifest symptoms.
"If there's any hospital executive who thinks this is not happening at their facility, I can tell you, they're wrong. If I were to look a CEO in the eye, I would say, 'You need to assume this is happening at your facility,' " Sherman says.
Later in 2012, Sherman was elected to the New Hampshire House of Representatives, where he helped write and pass two laws to thwart future drug diverters in the state's healthcare facilities. The first law requires all licensed facilities to establish a drug-free workplace policy that mandates education for employees to recognize behaviors of a drug diverter, and requires facilities to drug test employees for cause. Such programs might have enabled catching Kwiatkowski earlier.
According to a 176-page report on the Exeter case prepared by the state's Department of Health and Human Services, there were numerous tip-offs. For example, the report says, seven of 28 catheterization patients "reported experiencing higher-than-usual pain during the procedure." Also, seven staff members reported Kwiatkowski's "concerning behavior, including slurred speech, profuse sweating, bloodshot eyes, disheveled appearance, foaming at the mouth, and erratic behavior" that prompted them to conclude he was under the influence of drugs or alcohol. Though they reported these concerns to management—even before he became a permanent employee—"there was no documentation of an investigation or any disciplinary action" in his personnel file, according to the investigation.
Sherman says that without a drug-free workplace policy, hospital workers "aren't trained to look for those clues. They were more subtle at Exeter." Also, he says, "the guy was really beguiling, able to schmooze. And if he had to leave the room, he said he had some problem that caused him to leave the room frequently. He really had the whole system going.
"Often there are tip-offs," Sherman says, but he adds, "If the staff is not trained to recognize those, and policies aren't in place to report them, you're going to miss them."
The second law establishes a registry board for medical technicians, which Sherman says is the first in the nation, similar to those for physicians and other medical professionals that allow an employee's disciplinary record to be tracked when he or she changes jobs.
"It's true that this registry board would not have stopped Kwiatkowski," who came from another state through a staffing agency, Sherman says. "But we're hoping that at least this will make New Hampshire unattractive for people who want to misbehave, and will serve as a template for national efforts to develop similar medical technician boards in other states."
Sherman and Exeter officials are also working to pass a third bill that would protect healthcare providers from being sued if they share detailed information about former employees, "especially if those employees represented a risk to patients," says Mark Whitney, Exeter's vice president of strategy and community relations.
Since the tragedy at his hospital, "there's been a building awareness of how big this problem is, that it's a national issue," Whitney says, noting that in this case, the technician had worked at approximately 17 facilities across six states and that state laws are not enough. "We must come up with national solutions built on the New Hampshire model to prevent people like Kwiatkowski from moving from state to state."
Hospital leaders everywhere, he says, "should be proactive to push legislation like this through" in their states, and "encourage a national solution, so employees can't move from state to state and facility to facility."
Josiah "Sy" Johnson, CEO and chief mission officer at PeaceHealth's Columbia Network, echoes Sherman's warning for hospital executives who don't think they need to worry about drug diversion, saying a lot more of it goes on than hospital officials know. Johnson draws lessons from Exeter's experiences.
"I'm not sure that a lot of hospitals have invested in the right tools and the right access to the right information to help them know where the risks might be in the behavior patterns in their population," he says.
The 450-licensed-bed PeaceHealth Southwest Medical Center in Vancouver, Washington, last summer learned the hard way when the hospital—working with public health officials—had to offer hepatitis C testing to more than 900 previously hospitalized patients after one patient, someone who was a frequent blood donor and had tested negative in the past, now tested positive for the virus after "a hospitalization event."
A public health investigation couldn't find any other risk factors, Johnson says, but one of that patient's caregivers, who was suspended and is no longer with the hospital, had been under "a high level of suspicion" that he or she was diverting drugs.
"We put those two things together with public health and decided that the risk profile was significant enough to warrant testing of any other patient who had been exposed to that one caregiver," meaning any patients who had received intravenous narcotics during their stay.
The experience was a big wake-up call for PeaceHealth, Johnson says, and offered an opportunity to review its diligence about "the whole narcotic custody and utilization pathway and process, from the time it comes into our organization to the time the last unused dosage is properly disposed of.
"We reviewed that whole continuum, and looked for any ways that any one individual could find a way to divert."
An important lesson is to find ways through analytics and software programs to detect outlier users among your staff, he says. "You might ask, What's the dosage and frequency that are being dispensed? What is it at night? In the day? Are there caregivers who are statistically unusual in how much they dispense and the way they dispense? There are different ways you can slice the data."
Many organizations have access to this kind of information—for example matching patients' electronic health records with the logs from the dispensing machinery, "which shows what drugs the caregiver took to be given, and what was documented as given and how much. We had to do that for ourselves, in some cases manually, and found ways to make it more efficient."
But the investigations did not make some employees very happy, Johnson acknowledges, and that's something the organization needs to accept and confront.
"Our caregiver population was insulted and angered that there might be anyone in our midst who would have done this kind of thing, and saw the investigation as an affront. They said, 'Nobody here would do that.' "
The hospital reassured the workers by explaining that they had an obligation to deliver safe care, but also to help their fellow caregivers get help if they do have addiction problems.
Johnson suggests that hospitals grappling with where to start should look to the Mayo Clinic, a Rochester, Minnesota–based health system that has experienced drug diversion and resulting patient infections in at least three of its facilities over the past several years.
Keith Berge, MD, a Mayo anesthesiologist, has become a national expert and published author on the topic. Berge and his team have developed an elaborate 77 best-practices template, covering everything from chain of custody monitoring to witnessing and testing of wasted injectable opioid drugs when they're returned to the pharmacy, to make sure they were not replaced with something else along the way.
Tremendous effort was put into the Mayo prevention system because, Berge says, "our problem ended up on the front page of the Minneapolis Tribune; it caused a lot of angst at the highest levels. Our leadership realized, 'This is a very scary problem and we need to do whatever we must to make it stop.' "
At 358-bed Self Regional Healthcare in Greenwood, South Carolina, Senior Internal Auditor Anna Cuson, CPA, CFE, was investigating two confirmed drug diversion cases last fall, the first of which led to an inquiry, a confession, a termination, and notification to the board of nursing. In fact, she's called to investigate suspicious healthcare worker behavior about once a month.
That's why Self has developed a number of computerized systems to track healthcare worker drug administration practices. For example, Cuson says, "We'll look for instances of whole dose waste of, say, 1 milligram of hydromorphone. That would be a red flag, especially if we see it multiple times. Or we have someone consistently report that patients are dropping [tablets] they then say they have to waste."
In another recent case, a nurse was caught taking from the hospital dispensary machine a dose of the same medication that a previous nurse had already pulled, a duplicate dose. The patient got the medication, but so did the nurse.
Self also requires drug wasting practices to be witnessed. "Nurses get into a routine. They say, 'Oh, I work with her and I can trust her.' But they don't take that extra 30 seconds to actually take possession of the drug, look at it, and make sure hydrocodone isn't a Tylenol." The rules say that drugs that are wasted need to be disposed of within 30 minutes of the time they are pulled, so individuals seen carrying around drugs they say were to be wasted are automatically suspect.
Self has not had an instance in which drug diversion has impacted patients, but it has had many instances in which workers have been caught diverting, she says. "Even if you have the most robust prevention program possible, you're still going to have a 5% diversion rate, and 15% if you don't have monitoring."
Cuson says that Self does not use healthcare workers provided by staffing agencies because of Kwiatkowski, who had worked for such companies.
Kim New, JD, BSN, RN, a former compliance specialist at the University of Tennessee Medical Center in Knoxville who now is a full-time consultant with Bethel, Ohio–based Pharmaceutical Diversion Education and Knoxville-based Diversion Specialists, says she wants hospitals to be very careful about using staffing agencies.
"What I tell my clients is that if you use them, you need to make sure that their screening processes are at least as stringent as your own, and they should be willing to share that information with you."
One of her clients who caught four nurses diverting drugs realized that all four had come from the same agency, New says. But nationally, she says, it's still an uphill battle getting many hospitals to realize this can happen to them.
"While some hospitals are taking this very seriously, even appointing a drug diversion specialist to work full-time, at a lot of hospitals where I've been invited to lecture, I still hear people say they've never heard of David Kwiatkowski."
Decision-support tools and continual monitoring of imaging study use are helping healthcare leaders limit unnecessary exposure and waste.
This article first appeared in the May 2015 issue of HealthLeaders magazine.
At Massachusetts General Hospital in Boston, getting red rated is not something staff doctors would ever boast about. It means that MGH analytics has determined the physician tends to order too many high-end imaging studies—like MRIs, CTs, or PET scans—without clinical justification based on the patient's symptoms.
Rather than revealing information that would influence a treatment decision or prognosis, those unjustified images are more likely to result in potential harm through radiation exposure, or lead to more imaging tests, patient worry, allergic reactions, or invasive procedures. Of course, this all adds to costs, which could hurt hospital scores on Medicare's spending-per-beneficiary efficiency measure.
"The biggest potential harm is over-diagnosis and the possibility of subjecting patients to downstream testing and emotional anxiety based on tests they didn't need in the first place," says James Brink, MD, radiologist in chief at the 199-bed facility.
"Our system enables us to encourage appropriateness reviews for high-end imaging exams."
After a decade in which physicians and observers focused on processes and outcomes, the pendulum is swinging back toward viewing volume as the best barometer of hospital quality.
Welcome back, Procedural Volume.
Your popularity as a way to measure hospital quality—that the more procedures a hospital or doctor does, the lower risk of complications and vice versa—has been on the wane. But now you're trending back up. Good for you.
Here's why:
On Wednesday, U.S. News & World Report published, as part of its annual Best Hospitals report, a special new set of ratings that evaluate hospital performance in five common surgical procedures and medical conditions. The expanded report, Best Hospitals for Common Care, found that patients who receive these procedures at low-volume hospitals have a much higher risk of death or complications, while patients at higher-volume facilities have a reduced risk.
On Tuesday, Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System announced their "Take the Volume Pledge" program. They will restrict their 20 hospitals and surgeons from performing any of 10 procedures if they don't do a minimum amount per year. They also encourage other hospitals to adopt similar policies, perhaps as a condition for granting physician staff privilege.
The Centers for Medicare & Medicaid Services has begun posting on a new Hospital Compare tabthe number of Medicare beneficiaries who received care for any of 64 medical conditions or surgeries at various levels of complexity. The idea is that an especially fragile patient may require a hospital with experience treating a more complex case.
John Birkmeyer, MD
"There is a pendulum swing back toward paying attention to the volume/outcome story now," says John Birkmeyer, MD, a surgeon, outcomes researcher, and executive vice president for enterprise support services at Dartmouth-Hitchcock.
So procedural volume is officially back in the game. Or maybe we're just re-recognizing volume with much more appreciation for the important role it plays.
Volume has had an interesting journey since it first came on the scene in 2001.
That's when the Leapfrog Group's survey, in an effort to help employers and patients make better choices about hospital care, became the first advocacy group to include procedural volume as a proxy for quality of care.
Leapfrog scored reporting hospitals on how often they performed six procedures, setting minimum numbers for each necessary for proficiency: coronary artery bypass grafts, coronary angioplasty, carotid endarterectomy, esophageal cancer surgery, abdominal aortic aneurysm repair, and high-risk obstetrics. Later came aortic valve repairs and pancreatectomies.
Leapfrog's move, which President Leah Binder says garnered criticism at the time, was based on numerous studies published in the New England Journal of Medicine and other journals showing that procedure volume was just about the best quality measure going at the time, other than mortality, the ultimate outcome measure. Dozens of other quality measures were added in later years, diluting the impact of volume, but procedural volume persisted.
Birkmeyer, who has written many papers linking higher volume to better outcomes and advised Leapfrog in its move to use volume to guide choice of care, recalls those days as having "a huge flurry of attention to this from the lay media and professional [physician] societies. But over the next few years, volume as a measure for outcomes moved to the back burner."
That was partly because "the professional societies—the physician guilds—were successful in arguing that volume is just a proxy of quality and we should really measure outcomes and more direct measures of quality," for example infection rates or reoperation rates, "rather than getting so distracted with volume."
What followed was a new emphasis on process measures, such as timely administration of clot-busting drugs to heart attack patients, or giving surgical patients timely antibiotics, which correlate with greater success.
With the passage of the Patient Protection and Affordable Care Act in 2010, new penalty programs added readmission rates, patient experience survey scores, and infections to the equation of what determines high quality. And today, those measures are associated with adjustments to hospital pay that can represent nearly 6% of a hospital's annual reimbursement from Medicare.
Today, many of those measures are under fire as hospital officials point out bias or flaws. Counting avoidable 30-day readmission rates is controversial because it lacks an adjustment for socioeconomic status and unfairly punishes hospitals that treat the poor. Thirty-day mortality is important, but carries a low weight in the scoring formula, and may be more sensitive to patient comorbidities than the adjustment factor shows, some argue.
Last year, the Centers for Disease Control and Prevention acknowledged, and corrected this year, its measures for counting central line bloodstream and catheter-associated urinary tract infections. Previously, they were too vague and allowed too much interpretation and subjectivity, leaving hospitals to interpret what qualified and what didn't. Plus, thousands of hospitals didn't have enough cases to reach statistical significance.
Now, the CDC has clarified those infection reporting definitions. But hospital officials still argue they'll never get to zero, and what is a reasonable rate of hospital-acquired infections for different kinds of facilities remains in dispute.
So we're back to volume.
"Despite all the best intentions, consumers/patients still have a real paucity of information about comparative quality of surgeons and hospitals for elective but high-risk things," Birkmeyer says. "So the promise of better quality measures never really got there, certainly in any way that's meaningful to patients or leads to better choices."
So what is it about volume that makes it such a good measure for quality?
Ashish Jha, MD, director of the Harvard Global Health Institute, and a hospitalist at the VA Boston Healthcare System, agrees that volume is on the rebound. "But we're swinging back with a far greater sophistication of why volume is important than just 'practice makes perfect,' which is what we thought 15 years ago. It may be related more toward other components that come with larger volumes, such as more nurses per patient, better nutrition programs, or even having important equipment like a PET scanner."
Birkmeyer says Jha is "exactly right."
"It may have to do, too, with having a more coordinated team that surrounds the surgeon and is there after surgery," Birkmeyer says. "It means the scrub nurses and the anesthesiologists and other teams work well.
"And that if you're seeing a condition often enough, you're able to make good judgments about who needs surgery in the first place, and obviously making sure you do those surgeries well.
"It may be the team is good at not just avoiding complications but in rescuing patients when things start to go sour. With greater procedural volume, you become more adept in seeing when something isn't right, and taking the right steps toward pulling a patient out of the fire."
That's why for Birkmeyer and Binder—and perhaps patients—volume never really went away.
An initiative by three major U.S. health systems aims to "minimize the number of patients who wind up getting their care by so-called 'hobbyists,' surgeons and hospitals that seldom do these procedures," says one of its chief proponents.
Leaders at Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System are urging other systems to join their combined 20 hospitals in the "Take the Volume Pledge" campaign to place limits on surgical procedures.
The campaign aims to reduce complications linked to insufficient practice by setting minimum volume thresholds on 10 surgical procedures. The limits apply to hospitals and surgeons.
"We've gotten leaders at these organizations to draw a hard line in the sand so that no surgeon or hospital within these systems will allow those procedures unless they are meeting [certain] volumes," says John Birkmeyer, MD, a surgeon, outcomes researcher, and executive vice president for enterprise support services at Dartmouth-Hitchcock. He announced the "Take the Volume Pledge" effort this week.
John Birkmeyer, MD
"Our intent with these thresholds is not to set such a high bar that every patient must go to one of five places for surgical care," Birkmeyer says. "What we're trying to do is minimize the number of patients who wind up getting their care by so-called 'hobbyists,' surgeons and hospitals that seldom do these procedures, certainly not enough to attain a high level of honed proficiency."
The effort's first goal is to get hospital leaders to rethink whether they should allow surgeries to be done within their organizations relatively infrequently, and by individual surgeons who rarely tackle such operations. One option may be to tie surgeon volume with staffing privileges. "We'll worry at another time about outcome differences between medium volume centers and very high volume centers," he says.
Birkmeyer adds that if all hospitals in the U.S. "applied our standards, it would prohibit half of all hospitals in the country that do these procedures from continuing to do them. But just to be fair, looking at the volume distribution of these hospitals, you would only redirect 15% of the patients to other hospitals, because there are [not] so many hospitals now doing them that just don't do very many."
Quality measurement is nearly impossible for small-volume facilities and surgeons because the sample size is too small for statistical confidence, he says. "Most of the egregiousness of this practice comes from operations performed at very, very low volume hospitals."
Birkmeyer says that hospitals and surgeons who perform certain procedures infrequently aren't always doing them just because it's lucrative, which it can for smaller organizations.
"It's less because of the survival instinct and economics of high revenue surgeries. Instead, they're just accommodating the pride and professional autonomy that surgeons believe is their due. What hospitals do care about is running afoul of their surgeons and ultimately losing those surgeons who would go somewhere else."
The pledge campaign announcement comes as U.S. News and World Reportrolls out a new feature showing strong links between hospitals with high volumes and good outcomes such as fewer infections and low mortality, and hospitals with low volumes having more complications and higher mortality. The analysis uses Medicare data, and does not delve into volume for individual surgeons.
The 10 procedures were selected because of strong evidence that volume drives better outcomes, Birkmeyer says. For example, several published studies show that in rectal cancer excision, "surgeons who do very low volume have much higher odds of getting recurrent cancer."
The annual thresholds set by these three organizations are as follows:
Birkmeyer says that the time is right for many hospitals to launch such an effort as they work on mergers and acquisitions that bring smaller organizations together.
With quality ratings systems for consumers proliferating the initiative gives hospitals and surgeons a chance to take the lead.
"This is the first instance of an attempt where the provider community is trying to own this problem and lead from out front rather than be in a reactive mode," he says.
The American College of Physicians offers, for the first time, a way of thinking about whether or not and how much to screen for certain cancers.
Doctors and patients must stop thinking of cancer screening as an annual ritual that should find all cancers in the breast, colon, prostate, cervix, or ovaries. Instead, they should rethink whether certain types of screening in certain age groups is beneficial at all, or whether it will cause more harm and cost than it will help.
That's the thrust of two papers published May 19 in the Annals of Internal Medicineby American College of Physicians guideline experts Timothy Wilt, MD, of the Minneapolis VA Center for Chronic Disease Outcomes Research, and Russell Harris, MD, of the University of North Carolina School of Medicine and others.
"This is the first time that the ACP has come out with specific recommendations about these five cancers," says Harris. "It's also introduces a way of thinking about how we decide whether to screen or not, and how much to screen." He and Wilt are on the ACP's High Value Clinical Guidelines Committee.
Harris adds that the recommendations are expected to lead doctors and payers to think about measuring quality in terms of measuring rates of overdiagnosis.
"We've had these performance measures now [required by various payers to ascertain quality of physician care] that make doctors check the box how many screening exams they've done. But maybe we will start developing performance measures that give you demerits for overscreening. These are in the works and times are changing, gradually."
"When I was in training, the word overdiagnosis never came up," Russell says. "But the more we've learned, we realize that all cancers found are not necessarily the same. One cancer may be grow very rapidly, while another may not be growing at all. It's the middle ones we need to find out about.
"But if you start screening with high intensity, after a while you don't find many cancers in the middle. All you're finding is the slow growing and the fast growing ones."
The committee reviewed guidelines from the U.S. Preventive Services Task Force and several physician specialty groups to produce "high-value advice statements" for each type of cancer screening where there was agreement.
Some sample statements provided for clinicians screening for cancer:
For Breast Cancer
Discuss benefits and harms of screening mammography with average-risk women between 40-49 and order biennial screening if an informed woman requests it.
Encourage biennial mammography screening in average-risk women 50-74.
Do not screen average-risk women younger than 40 or older than 75, or a woman at any age if she has a life expectancy of less than 10 years.
For Cervical Cancer
Do not screen average-risk women younger than 21
Start screening average-e risk women at age 21 once every three years with cytology (Pap) tests without human papilloma HPV tests.
Do not screen average-risk women with cytology more often than once every three years.
Do not perform HPV testing in average-risk women younger than 30
Stop screening average-risk women older than 65 who have had three consecutive negative cytology, or two consecutive negative cytology plus HPV tests within 10 years.
Colorectal Cancers
Encourage fecal occult blood testing (FOBT) or fecal immunochemical tests (FIT) every year, sigmoidoscopy every five years, combined high-sensitivity FOBT or FIT every three years plus sigmoidoscopy every five years, or optical colonoscopy every 10 years in average-risk adults 50-75.
Do not screen more frequently than recommended in the above four strategies.
Do not screen in average-risk adults younger than 50 or older than 75 or those with an estimated life expectancy less than 10 years.
For Ovarian Cancer
Do not screen average-risk women.
For Prostate Cancer
Have a one-time discussion with average-risk men 50-69 who inquire about a prostate specific antigen screening to inform about limited potential benefits and substantial harms from the PSA
Do not screen using the PSA test in average-risk men 50-69 who have not had an informed discussion and do not express a clear preference for screening.
Do not screen using the PSA test in average-risk men younger than 50 or older than 69, or those whose life expectancy is less than 10 years.
Not Like Choosing Wisely
Harris says the ACP is not trying to design recommendations similar to the American Board of Internal Medicine Foundation's Choosing Wisely program.
"Choosing Wisely is about services that one should do less of, or maybe not do at all. But it doesn't talk about the place where you start doing it, how the intensity of doing screening should build, and the point at which you should stop," he says.
"The idea of screening intensity is important," he adds. "It means at what age, or how late in life, do you stop. And how you screen, by which screening tool. In breast cancer, for example, you could use MRI every year, starting at 30 and going to 95, but that would be very intense. The question is, if that's too intense, how intense should you be?
"ACP is looking at the recommendations and saying that starting at 40 is pretty intense, and you should talk with patients before you do that."
Clinicians and patients should see it as launching a cascade of events that can lead to benefit or harm.
They should regard cancers as not all the same, but with varying rates of growth from slow to fast and from asymptomatic to fatal.
Clinicians and patients should consider other life-threatening health risks when deciding to screen.
Screening leads to important benefits for some types of cancer, but "significant harms for many, many more" for example, compared with no screening, annual screening mammography for 10 years prevents about two breast cancer deaths for every 1,000 women at 50 years of age.
Determining the value of screening strategies is complex, but not impossible.
Physicians' self-regulation and professionalism is under intense scrutiny—much of it from inside the profession, as a remarkable series of JAMA opinion articles makes clear
If you're old enough, you can remember the doctor as part demigod, the sage Marcus Welby, MD, who always knew what was best. And drove a Chrysler.
But those days, like the TV show, are long gone.
Today,the would-be Dr. Welby stands—or rather, kneels—in a purgatorial circle, surrounded by accusations and suspicion from the public and his peers. Medicine's 50-year-old godly pedestal of self-regulation built on professionalism and integrity is cracking, or at least in need of major foundation repair. And doctors are very afraid of the flying debris.
That's the takeaway from this week's issue of The Journal of the American Medical Association, which is themed on the topic of "Professionalism and Governance." The issue contains 22 opinion pieces, an unprecedented number for a single issue in recent memory, says editor-in-chief Howard Bauchner, MD. All of the commentary focuses on the fermenting ire over the adequacy of our nation's standards for physician education, training, certification, staff credentialing, and discipline, many written by some of the biggest names in healthcare, like former CMS administrator Don Berwick, MD, and Joint Commission president Mark Chassin, MD.
The articles delve into how doctors do or don't learn what they need to know, what the public should expect, and the myriad impacts from dramatic changes in how they're paid and how they work. For example, the burdens and potential of electronic health records conversion and the public reporting of their performance on quality measures.
Today's Dr. Welby is surrounded by accusations he has not implemented new knowledge into practice, is overly obsessed with making money while unaware of cost's huge burden on the nation's healthcare system or his patients, and that he repeatedly overprescribes opioids without checking patients' drug-seeking histories.
From within their own ranks, doctors are charged with being beholden more to the needs of a corporate employer or a cost reduction strategy than to those of their patients, or that they practice in referral networks based sometimes on a you- scratch-my-back-I'll-scratch-yours philosophy rather than who is the best doctor to treat the disease.
Take this passage from one Viewpoint by Ezekiel Emanuel, MD, author and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania's school of medicine:
"Many of the important physician-driven problems affecting the U.S. healthcare system today relate to money: conflicts of interest of clinical researchers, physician evaluations based largely on the generation of relative value units, upcoding of services provided, the creation of physician-owned specialty hospitals that select and focus on caring for paying, healthy patients, the shift of sites of care not to improve patients' outcomes but solely to enhance reimbursement, the extensive use of medically unnecessary interventions, and providing highly reimbursed medical interventions when lower cost interventions are just as clinically effective."
Emanuel continued, "The real concern about professionalism is that money is corrupting the practice of medicine—that the pursuit of monetary gain for the physician is distorting judgments about what is best for the well-being of patients. All other threats to professionalism pale in comparison."
Failed expectations for doctors to keep up with state-required continuing medical education coursework prompts this Viewpoint from Steven Nissen, MD, chair of Cleveland Clinic's Department of Cardiovascular Medicine:
"Considerable evidence suggests that CME is unevenly applied within the U.S. healthcare system, and relatively ineffective in achieving the desired goals. … Physician knowledge of guideline recommendations for many important diseases is fair to poor, and adherence to these guidelines even lower.
"In a study of primary care physicians … who commonly treat patients with chronic obstructive pulmonary disease, only 33% knew the correct criteria for diagnosis," and in heart failure, only 27% of patients got guideline recommended therapies, Nissen wrote.
Nissen questions the sincerity of two-hour morning CME courses that take place in "resorts," allowing physicians to "enjoy recreational activities in the afternoon," and quoted a "highly critical" Josiah Macy, Jr. Foundation report that found 60% of the $2.4 billion spent on CME in 2006 was commercially funded, presenting "potential for bias" because of nonexistent firewalls that are supposed to be in place.
In his Viewpoint, "Professionalism, Self-regulation, and Motivation; How Did Health Care Get This So Wrong?" James Madara, MD, CEO of the AMA, rhetorically asks, "What is the role of professional organizations and societies in the medical profession's long-standing tradition of self-regulation, and what actions and influences might enhance the ability of the medical profession to operate effectively and responsibly?"
In a chart included in one JAMA editorial, authored by editors Bauchner, Phil Fontanarosa, MD, and fellow Amy Thompson, MD, readers are reminded that practitioners have been largely self-regulated by any of 17 nongovernmental, nonprofit standards and payment-setting organizations composed mainly of their peers.
They include the American Medical Association which establishes Current Procedural Terminology (CPT) codes; the American Board of Medical Specialties and its 24 member boards; The Joint Commission; the 70-member Federation of State Medical Boards; the National Board of Physicians and Surgeons; and numerous other groups that set minimum requirements for medical education curriculum and testing.
Much of the rancor of late, and the impetus for this themed issue, comes from new Maintenance of Certification requirements that physicians in 24 medical specialties must demonstrate to patients, payers, and the public to show continual learning in two-year cycles, Bauchner says. MOC requirements upended the old system, in which doctors merely passed an exam each decade and older doctors received lifetime exemptions after passing their first test.
New and extremely controversial requirements imposed by the largest professional certification board, the American Board of Internal Medicine, amid cries of profiteering and coercion, "have spilled over to other boards," raising the volume on the issue, Bauchner tells me.
"For me, and many others at JAMA, that issue led us to think about professionalism and self governance with respect to the entirety of medicine and not just recertification. We thought the best way of looking at undergraduate, graduate, and post-graduate training and other issues around professionalism was to solicit viewpoints by leading individuals in those areas.
"We also know that medicine is undergoing a fundamental change with more interest in value-based care and physicians being employed," he says. "It's possible that Medicare officials, or some other organizing authority, might step in to lay down rules that end doctors' self-governance."
Bauchner admits he is "worried that unless there are some very robust debates and discussion, medicine will lose what it's always prized, which is the very concrete, very substantial importance of self-governance."
"We're moving to far greater transparency than ever before. We know much more about physicians' conflicts of interest and where they get funds from. We know much more about physicians who bill Medicare and Medicaid at very high levels. That's absolutely in everyone's interest. But with that may come lack of clarity about what all that means. … It goes to the heart of what is professionalism."
Bauchner ended our conversation saying he hopes the themed issue will stimulate debate in a way that produces a solution to the rancor and noise. "Most of the organizations that formally oversee governance have no legal standing, so it really is a self-governing structure. And I think some questions need to be raised about whether this is the most effective governance structure."