Bariatric surgery can be an effective treatment for musculoskeletal and nonspecific pain linked to obesity. But postoperative pain treatment may increase the risk for chronic opioid use, researchers find.
New data on long-term, post-surgery drug use supports the case that opioids are a problem for bariatric surgery patients. For some surgery patients, long-term use of opioids increased steadily for the seven years of the study.
The researchers looked at data from more than 2,000 patients. Before surgery, 14.7% of the participants reported regularly taking a prescription opioid. That dropped to 12.9% after surgery, but rebounded to 20.3 % seven years after surgery.
Another group of subjects who were not taking opioids at the time of surgery, later began using them. Opioid use rates for that group rose from 5.8 % six months after surgery, to 14.2 % at the end of the study.
The type of surgery and and amount of weight loss were not associated with risk of post-surgery opioid use, but severity of pain was.
The data was collected as part of the Longitudinal Assessment of Bariatric Surgery. A group of six clinical centers worked with the National Institutes of Health to coordinate bariatric surgery research.
Bariatric surgery can be an effective treatment for musculoskeletal and nonspecific pain linked to obesity. But postoperative pain treatment may increase the risk for chronic opioid use.
Hydrocodone was the most commonly reported opioid medication, followed by Tramadol and Oxycodone. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not allowed due to a risk of marginal ulcers after bariatric surgery, leaving fewer nonopioid options.
"Our study does not prove that bariatric surgery causes an increase in opioid use. However, it does demonstrate the widespread use of opioids among post-surgical patients, thereby highlighting the need for alternative pain management approaches in this population," said study co-author Anita P. Courcoulas, MD, MPH, chief of minimally invasive bariatric and general surgery at UPMC in a statement.
The state has mandated data collection, eased into quality measurement, and made everything public.
Sparsely populated and not far from the medical mecca of Massachusetts, Maine is faced with many of the same health delivery challenges as other states. It is home to urban health systems and remote rural hospitals, all adapting to the value-based payment era.
The political battle over expanding Medicaid is raging, and so is the fight against the deadly opioid epidemic.
Yet according to the Leapfrog Group, a good percentage of the state's hospitals earn an "A" for quality—enough to make Maine the top state in the Leapfrog Group's hospital quality rankings this year.
Does the Pine Tree State have a quality blueprint it can share with other states? Not exactly. The well-established Leapfrog Group is just one many health quality measures, and no two states or ranking systems are alike.
For example, while still above the national average, Maine dropped from the No. 9 spot to No.15 in The Commonwealth Fund's 2017 "Scorecard on State Health System Performance."
Still Maine seems to have made some moves over the years that allowed it to ease into in the era of mega-measurement.
For one thing, the state began wrestling with quality measures more than a decade ago. In 2005, the state employee health plan began rewarding high quality hospitals by offering incentives to patients who used them. In order to do that, Maine had to put a system in place to measure quality.
Michael DeLorenzo is the chief operating office of the Maine Health Management Coalition (MHMC), an employer-led group. The organization was able to do that by deliberately engaging both providers and purchasers in the identification and development of quality measures.
"We don't think it is more complex than that," he said.
Other players include Maine Quality Forum, a state agency, and Maine Quality Counts, a non-profit that works to "implement practical health care quality solutions."
The National Academy for State Health Policy, in a 2010 report, identified five "key components" of successful state plans to improve quality. Here's how Mainers have put them in action.
1. Data Collection and Aggregation
Since 2003, the Maine Health Data Organization, a state agency, has collected claims data from commercial insurance carriers, third party administrators, pharmacy benefit managers, dental benefit administrators, Medicaid and Medicare.
The all-payer data is available to the public with the goal of providing a "useful, objective, reliable, and comprehensive health information database that is used to improve the health of Maine citizens."
The agency's website includes a long list of studies generated with the data. One recent analysis found "mixed results" in terms of cost, quality and utilization for the first two years of the state's medical homes program.
2. Public Reporting
The "Get Better Maine" website invites patients to "Learn which hospitals have the highest quality of care" through a patient portal sponsored by the Maine Health Management Coalition's Pathways to Excellence reporting program.
A state-mandated site called "Compare Maine" allows patients to compare the cost and quality of procedures at different facilities. Users can compare the average cost of more than 240 procedures at 150 healthcare facilities, along with a few quality data points.
For example, an entry on a screening colonoscopy shows an average cost of $3,800 in one hospital and $850 in another.
3. Payment Reform
The Commonwealth Fund, among others, cites the changes at the Maine Employee Health & Benefits program as one of the state's successful quality innovation.
In 2005, the insurer for 40,000 state employees and dependents began work on tiered provider networks and tiered benefits that adjust payments based on the quality and efficiency of care."
In addition, the state was part of the Patient-Centered Medical Home Pilot in 2010 and providers across the state have formed affordable care organizations.
4. Consumer Engagement
While policy makers and providers have been promoting the use of health data by consumers, Maine activists are also involved in promoting the expansion and quality of care.
More that 64,000 of them signed a petition that will put Medicaid expansion on the ballot in November. Maine's governor has repeatedly vetoed legislation supporting the added benefits.
In addition to Mainers for Health Care, Consumers for Affordable Health Care runs a hot-line to help people find coverage and a website with quality links. The Get Better Maine site includes a page with resources: "What to Do If You Have a Concern about Quality in a Maine Hospital."
5. Provider Engagement
The PTE (Pathways to Excellence) Steering Committees convened by the MHMC offers a forum for providers to help with the formation and refinement of the state's set of quality measures, CEO DeLorenzo said.
The group includes "leading primary care and specialty clinicians, quality improvement professionals, employers/purchasers, health plan and consumers," according to the MHMC site. When the group was unable to find the appropriate measures from national programs, it developed their own.
In its 2015 report on transforming health care, the Maine Hospital Association cited several other factors in the effort to improve care, including Maine Health Infonet, the statewide medical records system, and the formation of ACOs.
The MHA also convenes its own "Quality Council," a panel of 20 member hospitals that "analyze healthcare quality and patient safety issues."
The former CEO of a large safety net calls for a shift of healthcare dollars to social needs. She instituted such changes at her organization and simultaneously delivered " fabulous" care, and saved the system money.
The Lown Institute's annual conference began the day after the House of Representatives voted to repeal the Affordable Care Act. The Boston-based group is focused on "right care," a term that broadly refers to the delivery of appropriate care in a humane, costs-effective way.
You would think the conference attendees would be all over the Republicans, and they were, to a degree.
In his opening, virtual keynote, global economist Jeffery Sachs called the legislation an "attack on the poor" called its supporters "creeps" and worse.
Still, not everyone at the event was a huge supporter of the Patient Protection and Affordable Care Act. Sachs and some members of the "Right Care Alliance" have a vision of care that looks more like European single-payer programs. That those countries spend far less for better outcomes was a "right care" theme throughout the weekend. (It was also the theme of a January issue of The Lancet.)
So, what can a single hospital do? One of Saturday's keynote speakers, Patty Gabow, MD, the former CEO of Colorado's Denver Health, offered some ideas. Non-profit Denver Health includes the 525-bed safety net hospital, Denver Health Medical Center.
First, don't expect Congress to save the system. Instead, Gabow proposed a to-do list for health systems that is heavy on improving the social determinants that affect health, but also places a high value on such ideas as a living wage for all employees.
Gabow said she made similar changes in Denver, delivered high quality care, and saved her system money.
"You may wonder, after hearing that I spend 40 years at a healthcare institution, why I would pose a question like this: Can American healthcare deliver health? "she said.
"It is precisely because I spent 40 years at a safety-net institution that took fabulous care of patients. I saw every day that our patient had barriers to well- being and health." During and after the talk, Gabow elaborated on her list of what healthcare can do list.
Continue the efforts on access, cost and quality.
She cited lean innovations in management at Denver Health that translated into $192 million in financial benefits over seven years. They included supply chain and pharmacy management changes that kept money from going out the door and changes to revenue cycle management, such as getting the uninsured on Medicaid.
Gabow noted that patient behaviors such as tobacco use, diet, physical inactivity, alcohol and drug use and sexual practices cause as many as 40% of all US deaths. She noted that levels of obesity and drug abuse disorders are higher in the US than elsewhere.
She was adamant about the need to address the social determinants of health. To combat these realities she urged leaders to:
Contribute to community education on social determinants and advocate for addressing them
Co-ordinate community benefits to address social safety nets
Create linkages with social safety nets
Geographic variation reflects the impact of social needs on health, which leads some to suggest that "your zip code matters more than your genetic code in determining your life expectancy," Gabow said.
Invest in Social Care
To make her case, she compared Douglas and Denver Counties in Colorado. Douglas has fewer health facilities, but far more white, high school graduates. It has a lower crime rate than Denver and 11% of children qualify for free lunch. It ranks No. 1 in the Colorado county health rankings generated by the Robert Wood Johnson county health rankings.
Denver, which is home to more minorities and where 69% of the children qualify for free lunch, is ranked 38.
"When I meet the city council, I say 'We don't need more urgent care centers. We don't need more freestanding emergency rooms. We don't need more hospital beds in Denver. You need to invest in the social care system if you want Denver to look like Douglas County.'"
The way to do that, Gabow says, is by
Paying a living wage to all employees
Instituting robust tuition reimbursement programs
Reducing income disparity within their institutions
One of the keys to containing costs at Denver Health was "getting more care from the same number of workers" by treating and paying them well. For example, even though Denver Health is a safety next system, it offers a small tuition stipend to employees.
Gabow also suggested that hospitals look at the pay gap between hospital executives and other employees.
Ultimately, she is calling for a redistribution of healthcare dollars toward social needs. She acknowledged that won't happen easily or overnight.
We have to "take the time to understand what is working in our system, what is not working, and what is working in other countries," she told HealthLeaders.
She offered another way to look at it: "If someone told you that you could buy a car for half the price and it would last twice as long, you would probably want to buy it."
The former CEO of a large safety net calls for a shift of healthcare dollars to social needs. She instituted such changes at her organization and simultaneously delivered " fabulous" care, and saved the system money.
The former CEO of a large safety net calls for a shift of healthcare dollars to social needs. She instituted such changes at her organization and simultaneously delivered " fabulous" care, and saved the system money.
The Lown Institute's annual conference began the day after the House of Representatives voted to repeal the Affordable Care Act. The Boston-based group is focused on "right care," a term that broadly refers to the delivery of appropriate care in a humane, costs-effective way.
You would think the conference attendees would be all over the Republicans, and they were, to a degree.
In his opening, virtual keynote, global economist Jeffery Sachs called the legislation an "attack on the poor" called its supporters "creeps" and worse.
Still, not everyone at the event was a huge supporter of the Patient Protection and Affordable Care Act. Sachs and some members of the "Right Care Alliance" have a vision of care that looks more like European single-payer programs. That those countries spend far less for better outcomes was a "right care" theme throughout the weekend. (It was also the theme of a January issue of The Lancet.)
So, what can a single hospital do? One of Saturday's keynote speakers, Patty Gabow, MD, the former CEO of Colorado's Denver Health, offered some ideas. Non-profit Denver Health includes the 525-bed safety net hospital, Denver Health Medical Center.
First, don't expect Congress to save the system. Instead, Gabow proposed a to-do list for health systems that is heavy on improving the social determinants that affect health, but also places a high value on such ideas as a living wage for all employees.
Gabow said she made similar changes in Denver, delivered high quality care, and saved her system money.
"You may wonder, after hearing that I spend 40 years at a healthcare institution, why I would pose a question like this: Can American healthcare deliver health? "she said.
"It is precisely because I spent 40 years at a safety-net institution that took fabulous care of patients. I saw every day that our patient had barriers to well- being and health." During and after the talk, Gabow elaborated on her list of what healthcare can do list.
Continue the efforts on access, cost and quality.
She cited lean innovations in management at Denver Health that translated into $192 million in financial benefits over seven years. They included supply chain and pharmacy management changes that kept money from going out the door and changes to revenue cycle management, such as getting the uninsured on Medicaid.
Gabow noted that patient behaviors such as tobacco use, diet, physical inactivity, alcohol and drug use and sexual practices cause as many as 40% of all US deaths. She noted that levels of obesity and drug abuse disorders are higher in the US than elsewhere.
She was adamant about the need to address the social determinants of health. To combat these realities she urged leaders to:
Contribute to community education on social determinants and advocate for addressing them
Co-ordinate community benefits to address social safety nets
Create linkages with social safety nets
Geographic variation reflects the impact of social needs on health, which leads some to suggest that "your zip code matters more than your genetic code in determining your life expectancy," Gabow said.
Invest in Social Care
To make her case, she compared Douglas and Denver Counties in Colorado. Douglas has fewer health facilities, but far more white, high school graduates. It has a lower crime rate than Denver and 11% of children qualify for free lunch. It ranks No. 1 in the Colorado county health rankings generated by the Robert Wood Johnson county health rankings.
Denver, which is home to more minorities and where 69% of the children qualify for free lunch, is ranked 38.
"When I meet the city council, I say 'We don't need more urgent care centers. We don't need more freestanding emergency rooms. We don't need more hospital beds in Denver. You need to invest in the social care system if you want Denver to look like Douglas County.'"
The way to do that, Gabow says, is by
Paying a living wage to all employees
Instituting robust tuition reimbursement programs
Reducing income disparity within their institutions
One of the keys to containing costs at Denver Health was "getting more care from the same number of workers" by treating and paying them well. For example, even though Denver Health is a safety next system, it offers a small tuition stipend to employees.
Gabow also suggested that hospitals look at the pay gap between hospital executives and other employees.
Ultimately, she is calling for a redistribution of healthcare dollars toward social needs. She acknowledged that won't happen easily or overnight.
We have to "take the time to understand what is working in our system, what is not working, and what is working in other countries," she told HealthLeaders.
She offered another way to look at it: "If someone told you that you could buy a car for half the price and it would last twice as long, you would probably want to buy it."
They think they know a lot, research shows. But patient safety professionals are not as confident in trustee knowledge.
Hospital trustees are not usually chosen for their expertise in patient safety and quality of care. They are traditionally bankers, venture capitalists, drug company executives, real estate developers and manufacturers—what used to be called "captains of industry."
How much they know about patient safety and quality of care is not central to their joining a hospital board and has not been well quantified.
Now comes a study entitled "Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety." Published by The Joint Commission Journal on Quality and Patient Safety, it builds on previous research by asking hospital trustees how much they know about quality of care.
"Safety and quality leaders" (SQLs) were then asked for their impressions of trustees' knowledge and involvement with quality issues.
Researchers found hospital quality staff and trustees differ in their perceptions of how much board members understand and act on quality issues:
About 45 % of the SQLs said board members have a good understanding of teamwork, which is an important element of quality efforts.
About 77% or board members report that they understand the role of teamwork.
And
85% of board members checked off "All the time" to a question on how often patient safety events that caused harm are reviewed at the board's quality committee meeting.
40% of SQLs believe those cases are reviewed "All the time" at the meetings.
The gaps were smaller on other questions and the study does not suggest that executives and board members are not doing their jobs, says Patricia McGaffigan, RN, the study's lead author. She cautions that the study's size and methods make it difficult to generalize about the results.
McGaffigan, who is the Institute for Healthcare Improvement's (IHI) vice president of safety programs, suggests that hospital boards use the results to do a baseline assessment.
"This is a guidepost…"Here are some important areas that are provocative and help guide us to the priorities" that organizations may need to address, she says.
McGaffigan was with the National Patient Safety Foundation when she led the research. That group merged with IHI on May 1.
Training and Certification
The Minnesota Hospital Association helps its member hospitals address these issues by running a "Training Camp for Rookie Trustees" and a trustee certification program. Quality is a major part of those programs.
The knowledge gaps in the survey rang true to Lawrence Massa, the association's president. They have held trustee conferences for years, but the trustees wanted more education, he says. "The trustees felt like they wanted to be more of a partner with the senior leadership team."
That led to a broader effort with major safety and quality components. The handout for the trustee training camp includes a detailed description of every phase of the quality assessment process.
Involved, But Not Too Involved
"Too often boards of trustees assume that quality and safety problems are not an issue in their hospital unless they hear otherwise. Instead, boards should ask specific questions to identify the hospital's current performance and pinpoint areas with the greatest need for improvement," according to the document.
But hospitals don't want the trustees to get too involved.
"We try to be very clear about where the boundaries are between management and governance," Massa said.
The American Hospital Association recently "refocused" its trustee education effort, offering webinar and instructional video hospitals for "boardroom education."
Debra Stock, AHA's vice president of member relations, wrote in an email that most boards have quality review committees with deeper knowledge of the issues. All members don't all need the same level of proficiency in every area, she wrote.
Instead, boards need members with "a range of competencies including quality, finance, strategic planning, and information technology."
McGaffigan agrees. She says this study and others should motivate trustees and hospital administrator to work together to make sure quality is a priority in and out of the boardroom.
Holding SQLs Accountable
"It's a great time to have a conversation, to sit down as a team of executives and board member and SQLs [and] to say, 'what are our practices right now? What are the things we are doing that we think affirm that safety of patient?' [That] is a core value of ours," she says.
In an editorial accompanying the paper, consultant James Reinertsen, MD, agrees there is a gap between what boards know and what they should know.
He says that SQLs have to take some responsibility because they consume "vast quantities of precious meeting time with PowerPoint presentations." Board members listen passively and are not always encouraged to ask questions, Reinertsen writes.
If there is no opportunity to question, "a confusing aspect of the safety dashboards, or [to] challenge a management plan to correct poor performance or [to] dig into a particularly troubling matter concerning the medical staff, what would it matter how knowledgeable they are?"
Hiller Zobel, LLB, a retired judge and co-author of an updated book on doctors and the law, discusses how physicians can best help themselves when medical malpractice is alleged.
Doctors who do well in the operating room or emergency department don’t necessarily do well on the witness stand.
So retired Massachusetts Superior Court Associate Justice Hiller Zobel and Stephen N. Rouse, MD, childhood friends, decided to write a book to demystify the process for both defendants and expert witnesses.
Doctors & the Law, first published in 1993, has been updated for the digital age, with an e-book version and advice on dealing with issues raised by cell phones and the Internet.
The update, subtitled, “A guide for physicians entering uncharted waters,” was published earlier this year by CRICO, a group of companies owned by Harvard medical institutions to serve their medical communities.
Judge Zobel spoke with HealthLeaders about the updated book recently. The transcript below has been lightly edited.
HLM: Why did you decide to write this book?
Judge Zobel: I had seen enough doctors on the stand, not just in malpractice cases, but generally, to know that they could use a little help in being a witness.
HLM: What is the most important message of the book?
Judge Zobel: The general message to a doctor who's sued is: Of course, you think the world is ending, but it really isn’t and things are better than you think.
This book will help you to deal with what is a traumatic experience. The chief message to a doctor who is testifying or is an expert witness is this: Listen to the question, understand the question, answer the question and shut up.
HLM: Why do they need to shut up?
Judge Zobel: Doctors, particularly doctors who are sued, feel that it is essential for them to explain everything. In doing that, they expose themselves to further cross-examination and serious pitfalls. As an expert, they expose themselves to being cut up [by the opposing lawyer] and, in essence, discredited.
HLM: Why do you think it is so traumatic for doctors when they get sued?
Judge Zobel: One of the reasons doctors get into medicine in the first place is to help people. People come to them for assistance, and the doctor does his or her very best to help the person, cure them, or at least deal with their medical problems.
All of the sudden, one of the people the doctor has been trying to help turns on him. That’s a very deep blow to anybody, but particularly to a doctor because the doctor’s whole frame of reference in dealing with peopled is 'I'm here to help you and getting you better is the most important objective for me.'
There is also an element in the doctor’s reactions of 'I didn’t do anything wrong. Why are they saying I did something wrong?' Or 'maybe I screwed up somehow,' or 'maybe I shouldn't have prescribed that particular medication. Or 'maybe I should have asked for a particular test I didn’t ask for.'
In other words, the feeling that maybe the physician dropped the ball somehow. Of course, occasionally there is the feeling of 'I sure blew it, I know I blew it.'
HLM: Doctors sometimes cast themselves as victims of frivolous lawsuits. Do you agree?
Judge Zobel: I think that perception is flawed. The fact of the matter is that nine cases out of ten that go to trial result in a verdict for the defendant. People like doctors more than they like lawyers. Most of the time, the case is for the doctor to lose rather than for the plaintiff to win.
I charged a jury in a malpractice case that malpractice is really another word for a particular kind of negligence. And negligence is carelessness, that is, failing to do something a reasonably competent physician would have done, or doing something a reasonably competent physician would not have done.
The jury came back with a plaintiff’s verdict, and I got a letter from the doctor saying 'I resented what you charged to the jury. I am not a careless doctor. I’ve been in practice for 30 years and no one has ever accused me of being careless.
I wrote him a note, and I pointed out to him: The question is not what you’ve been doing for 30 years. The question is what you were doing on that particular day or did at that moment.'
HLM: What new ground does the book cover?
Judge Zobel: The statutes differ across the country, but the general idea is that when the doctors say to the patient, or more likely to the patient’s survivors: 'I’m very sorry,' what the doctor says under those circumstances can’t be held against him or her.
I think that’s very important because the first thing the patient wants to know or what the survivors want to know when something obviously went wrong is what went wrong and how did it happen?
The doctors do not have to give a detailed description of why it happened. It suffices to say: We don’t exactly know and were going to find out, and of course we are going to tell you.
HLM: One of the big changes since the last book is the rise of the Internet. What does that mean for physicians?
Judge Zobel: It means that the doctor’s professional life is pretty much open. If the doctor has written articles, other people will find them.
HLM: What would you say to doctors who want to play a role in their defense?
Judge Zobel: I would say in the first place, 'You are not going to be doing any of the talking. Therefore, you are going to have somebody working with you who knows what he is doing.'
It is very similar to being a patient and going into the operating room. There is the surgeon. There is the anesthesiologist. They know exactly what they are doing.
The fact that you don’t know, in a general way, what is happening [in a legal case] is beside the point. As the old vaudeville line goes, 'You’re not the head man in that show.'
A Yale study finds that while patients have difficulty envisioning the benefits of avoiding low-value care, they are clear on one point: They would like doctors to spend more time talking and less time testing.
Choosing Wisely has become a healthcare call-to-action not unlike the "triple aim" and, increasingly, "measures that matter."
The doctor-driven campaign to reduce the use of unnecessary care needs to reach two audiences, doctors and patients. Its message to doctors: Think twice before ordering that test or starting that treatment. Its message to patients is less clear, according to a study out of Yale.
The Yale study cites the Choosing Wisely campaign throughout, but its aim was to look, not at that program specifically, but at how well the public understands the concept of low-value care.
The paper found one-third of those surveyed "have difficulty envisioning benefits from avoiding low-value care."
Mark Schlesinger, a professor of health policy at the Yale University School of Public Health, is the lead author of the study. He lauds the American Board of Internal Medicine, which launched and shepherds the Choosing Wisely campaign, but says ABIM has "a hard message to communicate."
The study, which appeared in the Millbank Quarterly, involved focus groups, interviews and a national survey of more than 900 people. They were asked questions such as this:
"People will sometimes talk about doctors being especially good at avoiding tests and treatments that are likely to have more risk than benefit. If you were to hear or read that a particular doctor was good at this, what—if anything—would you expect them to do differently from most other doctors?"
The researchers found that two-thirds of those surveyed "had some sense of what low-value care might entail, though many were uncertain about the specifics." Additionally:
Many who offered a description of low-value care saw it in terms of only testing, not treatment.
About 5% "anticipated that excessive medical care might harm patients."
About 1% made a link between low-value care and medical costs – either their own or the nation's.
Even though some healthy respondents could not envision how unneeded tests could be harmful, patients with a history of serious illness knew exactly what it meant. Many reported "personal exposure to duplicated tests."
Patients were more concerned about the "opportunity costs," the use of time off or other resources needed to receive treatments with little clinical value. That was an issue for lower-income patients "whose life circumstances often make it challenging to find time for needed medical care."
What is 'Low-Value' Care?
Researchers also found disparities in patients' ability to define low-value care. They asked respondents to offer a description of what it would mean for a doctor to avoid low-value care. College graduates were much more likely than those without a high-school degree to offer a description. All minority groups were less likely than whites to be able to describe what avoiding low-value care might involve.
Schlesinger says ABIM has tried to reach out to patients through its affiliation with Consumer Reports. But, it may reach mainly highly educated, savvy consumers and not "the general public as well," he says.
The paper states: "The public's awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status."
Schlesinger says that once they were done with their eight focus groups, it became clear what patients want their doctors to do more of, talk to them.
They had a hard time imagining that a test could be bad for them, but he says they would be willing to put off tests in exchange for more time with their doctors.
'Start Simple'
"What we heard a lot from people was that they were happy if their clinicians would start simple with them," Schlesinger says. "Start by talking to them. Start with simple test and treatment, and always have the option of going to the more expensive, the more elaborate, the more invasive."
They don't want to be told they can never have those tests. "They were looking for the kind of care that would be more personalized and more personal than just throwing tests and treatments at them," he says.
Lessons
"The big threat that they saw was that doctors would become routinized, mechanized, and technology-centric rather than person-centric."
Daniel Wolfson, chief operating officer of the ABIM Foundation, believes there is much to learn from the Yale study. One key message is the willingness of patients to forgo some care for more time with a doctor.
But Wolfson does not think the study is designed to measure whether patients are getting the Choosing Wisely message. He sees it as a look at the language that is used to frame the discussion, noting that the ABIM doesn't use the term "low-value care" because it doesn't resonate well with patients.
Choosing Wisely is not meant to be a general public awareness campaign, Wolfson says. It is meant to start conversations. Many will occur between patient and clinician at the point of care.
In addition to those chats, Choosing Wisely has launched a national discussion about overuse, a topic that was once erroneously associated with a move toward rationing and so-called death panels, Wolfson says.
"Now we are having a rational conversation about important issues," he says.
Data from The Leapfrog Group's doesn't match Medicare data and suggests a lack of reliability in self-reported data, researchers say. Leapfrog says it "goes to extreme lengths" to verify survey data.
In the search for hospital quality measures that matter, all kinds of rating systems are coming under scrutiny, including those used by the Leapfrog Group, a nonprofit advocate of quality and safety in healthcare.
A study from the University of Michigan concludes that the group's Safe Practice Score (SPS) produces different results than those used by Medicare's Hospital Compare to track common complications and readmissions.
The Leapfrog findings "skew toward positive self-report[ing]," according to the study, which appeared in the journal Medical Care and was entitled "Dissecting Leapfrog."
The researchers suggest that some of the differences could stem from "selection effects." Hospitals may be more likely to share information if they generally earn high scores, they write.
"Alternatively, given that hospitals have a clear incentive to score themselves highly, participating hospitals may inflate their SPS reports, resulting in the skewed distributions and undermining the measures' predictive value," they write.
And they note that Leapfrog makes efforts to validate data. It requires "a letter of affirmation" and flags erroneous or misleading reports.
Leapfrog Responds
In a written response to the paper, Leapfrog notes that, while it is possible to "game any ratings system, we find that hospitals attempting this with the Leapfrog Hospital Safety Grade are generally frustrated by the result."
The organization's safety grade is based on 30 measures, "meaning that there are thousands of potential statistical outcomes that cannot be predicted with certainty."
In terms of the reliability of voluntarily reported data, the Leapfrog statement notes that the organization "goes to extreme lengths" to verify survey data. This includes on-site verification at randomly selected hospitals, and independent review of each survey response.
Leapfrog also suggests that the disparity between its own data and that of Medicare could be linked to a difference in data reporting periods or to a difference between Medicare data and Leapfrog reporting at "individual bricks-and-mortar facility level."
Leapfrog notes that there are different ways to measure safe care and the organization doesn't expect its findings to "correlate 100%" with other scores.
A critical care physician reports that treating sepsis patients with Vitamin C and steroids results in "very short" lengths of stay and lower readmission rates. Critics say a randomized controlled trial is needed.
Sepsis can be unpredictable, fast moving, and fatal. The condition has been identified as the number one reason for readmissions and the most costly.
So, when a paper in Chest described patients who recovered with an infusion of steroids and intravenous vitamin C, it got a lot of attention, not all of it good.
The study's lead author, Paul Marik, MD, a critical care physician at Eastern Virginia Medical School in Norfolk, VA, calls the study preliminary and agrees that more data is needed.
But he thinks the sepsis regimen is safe enough to start using now. HealthLeaders talked to Marik this week. The transcript below has been lightly edited.
HealthLeaders: What was the response to the Chest paper?
I did get some pushback from people who said, 'you can't do this.' But actually, we can. Steroids and thiamine are highly available.
There is an enormous amount of literature on critically ill patients who have almost undetectable vitamin C levels. That is quite appropriate to replace. If you look at the package insert, it says IV vitamin C is indicated for patients with acute deficiency of vitamin C.
HealthLeaders: Are there side effects?
Marik: We were quite comfortable in doing this. In the dose we used, there were no side effects. You always have to be careful that there is no potential for harm. In the dose we use, it is completely and utterly safe.
HealthLeaders: What should hospital administrators know?
Marik: Patients will come to our ICU in septic shock. They will leave three days later with no organ failure. From the hospital's perspective, this is very big.
They don't go into renal failure, so there is less requirement for dialysis. The leave the ICU and the hospital more quickly and the length of stay is very short.
Their readmission rate is much lower; sepsis is a bad thing with all kinds of organ dysfunction. They leave much healthier.
Our (president) is delighted by this because he sees the real data and he can tell that the length of stay is down, the use of resources is down… the mortality is down.
He is ecstatic… This a no brainer and a win-win situation.
HealthLeaders: What are the costs?
It costs $40, which is less than that of an antibiotic. It shortens the length of stay, it doesn't have all these complications, which are very resource-intensive and very expensive. And patients leave the hospital well.
HealthLeaders: Are there other benefits from the treatment?
Marik: There was a randomized controlled trial in hospitalized patients with low levels of vitamin C. Researchers looked at patient's mood and happiness and they found that patient who got vitamin C, their mood was better and they had a higher happiness index.
So our motto is they leave alive and they leave happy.
HealthLeaders: Isn't this an off-label use? Don't we need randomized clinical trials?
Marik: I've got a lot of feedback because people think this is BS and hocus-pocus and unscientific.
It's based on very sound scientific principles. This becomes important because we think, in our setting, it is unethical not to do it.
People say we need a randomized trial before we do it. This is what we are trying to do, and I'm trying to get other people involved, but that will take time.
To do a [randomized control trial] you need a lot of money and it takes three or four years… In the meantime, millions of patients are going to die while they wait. I say, what have you got to lose?
I have colleagues across the country who are using it, and they are telling me they are seeing exactly what we see. There are other people who just won't do it.
I was in Seattle at a sepsis conference two days ago. The audience was half nurses and half physicians. The nurses thought it was the coolest thing in the world and were really excited and wanted to do it.
Half of the physicians thought was cool and the other half thought it was nonsense and they wanted more data. That's where we sit now.
HealthLeaders: How did you come to do this study?
Marik: It was not my goal to find a cure for sepsis or anything else. When you have really sick patients, you have an obligation to them to do the best you can and to think out of the box.
This started last January. We had this 53-year-old lady who was otherwise previously well… It was clear to me that she was going to die from sepsis.
Dr. [Berry] Fowler from Virginia Commonwealth University had sent me a paper on stuff he had done on vitamin C… When I was faced with this, I remembered and thought, maybe I should try this.
I pulled out his paper to get an idea of the dose. I thought, why don't I use steroids with it, because maybe they will work together?
The next day when I came to work, I was shocked to find that she was off all the vasopressor agents. She was extubated two hours later. Her kidney function improved. She left the ICU three days later.
So, we started using it cautiously in more patients and found exactly the same thing.
We thought we had an obligation to continue to do this because this is such a bad disease and [we] see patients turn around.
Doctors have been slow to adopt a recommended short form of radiation therapy for early breast cancer. Data shows it has the potential to save millions of dollars.
Clinicians and patients can be slow to adopt evidence-based approaches to care, despite widespread agreement that unnecessary care can contribute to high healthcare costs.
But cheaper care can be adequate care both in a clinical sense and a financial sense. The slow uptake of evidence-based clinical guidelines and recommendations comes with a price.
Researchers from Duke University Medical Center found huge savings when doctors used a recommended short course of radiation therapy for women with early stage breast cancer.
Still, fewer than half of those eligible for the preferred approach to radiation therapy got it. The researchers estimated that one year of extra care cost $164 million.
Of the patients who were eligible for the shorter course of radiation therapy or no therapy at all, 57% were treated with the longer, costlier regimens. The four-week course of radiation therapy was estimated to cost $8,000, as opposed to the $13,000 traditional six-week regimen.
Numerous studies have shown both treatment approaches to be equally effective.
The costs of treating the national cohort was about $420 million during 2011. Had these patients been treated with the preferred regimen, the bill would have been $256 million. The 39% difference translates to $164 million in savings.
Recommended Treatment
Numerous, large clinical trials have shown that the short course works as well as the long course. That's how it ended up in the guidelines of both Choosing Wisely (contributed by the American Society for Radiation Oncology).
The Duke study's lead author, Rachel Greenup, says the findings reveal that, in this case, quality doesn't have to be sacrificed to reduce costs. "All the stars sort of align in this example," she says. "Women get high quality care at a lower cost and it decreases their treatment burden."
"Culturally… many people have a sense that backing off of healthcare, especially in cancer, is going to harm them or compromise the care they get," she said. Many women who qualify for lumpectomies, for example, continue to opt for mastectomies, despite similar outcomes.
Medical Maximizers vs. Medical Minimizers
While the Duke results don't explain why some breast cancer patients get more care, Brian Zikmund-Fisher said patient choice is a possible factor.
Zikmund-Fisher is a researcher who studies health behavior at the University of Michigan in Ann Arbor. He is one of the authors of a study that proposes a scale to measure of whether patients are medical maximizers "who are predisposed to seek healthcare even for minor problems," versus medical minimizers "who prefer to avoid medical intervention unless it is necessary."
"It is entirely plausible that part of what is going on here in the context of these radiation decisions is that the patients who are minimizers are agreeing and saying 'Oh good. I don't have to do more,' but the patients who are maximizers are asking physicians to do everything possible," said Zikmund-Fisher.
Physician Attitudes
Then it's up to the physicians to push back. But for many reasons, some are not comfortable doing that. Their reluctance stems in part from physicians' perceptions that patients would find it difficult to accept less treatment.
Sometimes physician reluctance is driven by the ambiguity of guidelines, but that's not the case with hypofractionation treatment for early stage breast cancer.
Kilian Salerno, MD, director of breast radiation at Roswell Park Cancer Institute in Buffalo, New York, will be speaking on the topic at this week's NCCN annual conference in Orlando.
She notes that there has been a slow, but steady increase in the use of hypofractionation. The hope is that guidelines like those from NCCN and Choosing Wisely will inform physicians about the strong evidence supporting the approach.
Hospitals can also use the guidelines to do a self-assessment to determine whether their practices are consistent with the recommendations calling for the shorter course of radiation.
"If a practice were not ever utilizing this [treatment], and has large number of early-stage patients, it would be time for education," Salerno said.
