Quality and safety

Elective Coronary Stenting: A Case in Context

August 3rd, 2011 | No Comments | Source: Commentary

The Case
In 2009, administrators at St. Joseph Medical Center in Maryland wrote letters to the patients of Mark Midei, MD, informing them that its staff cardiologist may have subjected them to a coronary artery stenting procedure inappropriately. That communication prompted an article in a local newspaper, which triggered an investigation by the Senate Finance Committee.

The Committee subsequently released a report which asserted that Midei performed nearly 600 stenting procedures unnecessarily, and charged Medicare nearly $4m for these procedures. According to the report, all the procedures involved stents made by Abbott Labs. Abbott, in turn, had paid Midei $31,000, added him to its roster of top stent volume cardiologists, and feted him with a pig roast at his home to celebrate a prodigious day in which he implanted 30 stents (apparently a company record). Then, after St. Joseph’s dropped Midei from its roster, Abbott hired him to provide services in Japan and China. In the subsequent year, the number of patients who received stents at the hospital fell to 116 from 350 in the previous year.

Most recently, the Maryland Board of Physicians revoked Midei’s license to practice medicine after concluding that he inappropriately implanted stents into the coronary arteries of 4 patients. The Board also determined that he exaggerated the severity of coronary blockages and claimed incorrectly that they had unstable angina. Midei has denied the allegations and sued St. Joseph for damaging his career.

The Context
The Midei case is particularly egregious, but a recent study in the Journal of the American Medical Association suggests that many thousands of percutaneous coronary interventions (PCIs)—perhaps as many as 4% of all those performed each year in the US—are inappropriate.

The study was organized by Paul Chan of Saint Luke’s Mid America Heart and Vascular Institute. Chan’s team found that when PCIs were done for acute indications like an evolving myocardial infarction (heart attack), the overwhelming majority of cases (98.6%) were performed for appropriate indications. A remarkably low 1.1% were done inappropriately (in the other cases, the benefit was uncertain).

For elective procedures like the ones performed by Midei however, fully 11.6% of all PCIs were inappropriate, and an additional 38% were carried out for indications associated with unclear benefit. Most of the procedures deemed to be inappropriate were carried out on patients with no angina (54%), low-risk ischemia as determined by exercise testing (72%), or patients that were not receiving ‘maximal’ medical therapy (96%). Ninety-four percent of these patients also did not have ‘high risk’ coronary anatomical findings. (more…)



Screening and Prevention: Separating the Wheat from the Chaff

July 6th, 2011 | No Comments | Source: Commentary

In the last month, the Obama administration announced programs to reduce racial disparities and increase prevention in health care. Neither program was funded with actual money, so they are about political showmanship as much as any real desire to tackle the worthy causes. After all, who would oppose such programs? I half-expect the administration to follow-up these announcements with one focusing on moms and apple pie.

But have a closer look at what Iowa Democrat Tom Harkin said at the press conference introducing the latter initiative. “For every dollar we invest in prevention, we save $6. We need to provide an approach that makes it easier to be healthy and harder to be unhealthy.”

I haven’t found the report on which Harkin bases his assertion about the returns on health prevention efforts, but my sense is its more complicated than Harkin would have us believe. Some screening and prevention programs are not effective at all. Others are effective, but prohibitively expensive. Any national program to improve prevention needs to evaluate each potential component to assure it reflects Harkin’s focus on cost-effectiveness.

Many recently proposed screening programs do not meet this criterion, in fact. Let’s take a look at a few of them.

Screening for Prostate Cancer
Two months ago, scientists reported the results of a 20-year follow-up study of 1,500 Swedish men between the ages of 50-69. The study found that routine screening for prostate cancer did more harm than good. The screening program (which included digital rectal exams and prostate-specific antigen tests) enabled physicians to detect and treat nearly a third more cancers, but there were problems with overtreatment and treatment related side-effects. More importantly, prostate cancer death rates were the same in the screening group as they were in the control group. (more…)


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Racial Disparities in Health Care: The Hundred Years’ War

May 18th, 2011 | No Comments | Source: Commentary

It was 1999 when the Federal government first acknowledged our nation had a problem with race and health care. That year, Congress tasked the Institute of Medicine to study the matter, and the resulting report was not good. Minorities were in poor health and receiving inferior care, the report said. They were less likely to receive bypass surgery, kidney transplants and dialysis. If they had diabetes, they were more likely to undergo amputations, meaning their disease had been poorly controlled. And there was a lot more where that came from.

The IOM report was a call to action. In subsequent years, lawmakers crafted policies and established goals for improvement. Federal and state governments and numerous foundations set aside billions to fund projects. Health services researchers expanded their efforts to study the problem.

Twelve years later, we have something to show for the effort. Steep declines in the prevalence of cigarette smoking among African Americans have narrowed the gap in lung cancer death rates between them and whites, for example. Inner city kids have better food choices at school. The 3-decade rise in obesity rates, steepest among minorities, has leveled off.

Nevertheless, racial disparities persist across the widest possible range of health services and disease states in our country. The overall death rate from cancer is 24% higher for African-Americans than white people. The racial gap in colorectal cancer mortality has widened since the 1980s. African Americans with diabetes experienced declines in recommended foot, eye, and blood glucose testing between 2002-2007.

Why is this problem so hard to solve?
The reason is that the problem is exceedingly complex. Hundreds of factors contribute to racial disparities in health care. Progress on just a few of them is therefore unlikely to move the needle much (which isn’t to say we shouldn’t try!). The key contributing factors are these:

Identifying Target Populations-Studies of racial disparities in health care rely fundamentally on tools that classify people by race. These tools are notoriously imprecise. Most of them classify all people whose family immigrated from a country that was once considered part of the Spanish empire as “Hispanic,” for example.  This means people of Panamanian, Mexican and Venezuelan descent are grouped together (to name but 3 countries).

The resulting “Hispanic population” in studies of health disparities is actually a polyglot of culturally-driven lifestyle choices, tendencies to seek care from physicians, and dozens more behaviors that impact health. This heterogeneity severely undermines the value of information obtained from the studies.

The Genetics Don’t Work: The genes responsible for phenotypic traits that forensic pathologists and anthropologists use to study race aren’t the same ones that govern how sodium-potassium ATP pumps work (and how they impact hypertension risk, for example). They have nothing to do with the genes that govern the body’s tendencies to store fat and establish a basal metabolic rate (and how they impact obesity risk). In fact race is largely a red herring in the search for genetic links to cardiovascular disease, cancer and other conditions that kill US minorities disproportionately . (more…)


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New Alzheimer’s Guidelines: Better Late than Never

April 25th, 2011 | No Comments | Source: Commentary

For the first time in 30 years, an expert panel has updated guidelines for the diagnosis of Alzheimer’s disease. The long overdue facelift should favorably impact care for millions and accelerate badly needed research on the disease.

The guidelines were produced by representatives from the National Institute on Aging and the Alzheimer’s Association. They portray Alzheimer’s for the first time as a three-stage disease. In addition to ‘Stage 3,’—the full-blown clinical syndrome that had been described in earlier versions of the guidelines—the new guidelines describe an earlier ‘Stage 2,’ of mild cognitive impairment due to Alzheimer’s, and a ‘Stage 1, or preclinical’ phase of the disease. The latter can only be detected with biochemical marker tests and brain scans.

The guidelines legitimize years’ worth of observations by the family members of Alzheimer’s patients, who recognize in retrospect that Grandpa had a slowly progressive cognitive disorder long before he was diagnosed. The guidelines also reflect progress on the research front, where it has now been established that the disease begins years before patients become symptomatic.

Alzheimer’s patients and their families, and the teetering US health system that supports them, would have been better served by the publication of these guidelines 2-3 years ago.

The science was compelling enough back then, and a 2 to 3 year lead-time on research could have had an enormously positive impact on our economy and our health system. In a report last summer for example, the Alzheimer’s Association concluded that unless disease-modifying treatments are found quickly, the number of Americans with Alzheimer’s disease will jump from 5.1 million to 13.5 million by 2050. The total costs of caring for these folks will have exceeded $20 trillion, in today’s dollars, by then. A lions’ share of these expenses will be borne by government entitlement programs, Medicare and Medicaid.

The New Guidelines Will Improve Care
Meanwhile, several commentators have criticized the new guidelines as confusing and stress-provoking. ‘Why should we rush to tell people they have something we can’t treat?’ is the crux of their argument.

These people have it wrong. Denial is not the way to go with Alzheimer’s. The sooner patients and their families find out they have it or are at risk to develop it, the more time they have to develop care plans that reflect their preferences. Mildly affected individuals get to decide for themselves how to enjoy what may be a limited number of years-worth of relatively unimpaired mental functioning. They also get to decide whether to participate in clinical trials and which ones to participate in. They and their families can access counseling and support groups more quickly, a benefit that can improve the quality of life for everyone involved. Even providers themselves can use the enhanced lead-time to implement a patient support plan that respects the needs of the patient and his family.

Today, full-blown Alzheimer’s affects 5.1 million Americans. In all likelihood, at least that many have mild cognitive impairment due to Alzheimer’s (the new ‘Stage 2′). These are the people that will benefit immediately by the expanded definition.

The New Guidelines Will Improve Research
By formally recognizing that Alzheimer’s is slowly progressive and establishing criteria for each stage of the disease, the guidelines facilitate scientific inquiry into various diagnostic and therapeutic options. They allow patients to be grouped by stage of illness (a breakthrough similar to what tumor staging has done for cancer research). Most importantly, they encourage patients to enter clinical trials at a time in the natural history of their disease when treatment success is more likely. (more…)


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What to do when your Child has a Fever

April 4th, 2011 | No Comments | Source: MedPageToday, NPR, Pediatrics

Other than a prolonged tantrum perhaps, nothing upsets the normal give-and-take between parent and child more than a child who is running a fever. Mild temperature elevations are usually a benign, physiologic response to a mild viral infection. Yet many well-meaning parents give their kids medicine for no other reason than to keep the temperature down. As if treating the fever was the same thing as treating the virus.

Now, a task force from the American Academy of Pediatrics has advised physicians and parents that a fever, in and of itself, should not be a cause for concern, and that parents should not bother  treating low-grade fevers in kids unless they are demonstrably uncomfortable because of the fever.

In short, parents should try to keep kids comfortable rather than reducing their temperature to a pre-determined number.
The viruses that cause most fevers typically last just a few days and cause no harm. And although febrile seizures do occur, the group says anti-fever medicine don’t necessarily prevent them.

“There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications,” the report stated. In fact, fever is one mechanism by which the body fights viral infections. It slows growth and reproduction of the germs that typically cause fever and enhances neutrophil and T-lymphocyte production, for example.

According to the report, nearly half of all parents believe (incorrectly) that a temperature less than 100.4 degrees constitutes a fever, and nearly 25% would give antipyretics to their children for temperatures less than 100. And nearly 85% of parents would awaken a sleeping child if it was time to administer a dose of anti-fever medicine.

That’s unwise. “If they’re sleeping, let them sleep,” Henry Farrar, an emergency room pediatrician and report co-author said in an interview. (more…)



Health Wonk Review: Spring Training Edition

March 17th, 2011 | 3 Comments | Source: Commentary

Spring training 2011 is in full swing. With baseball’s regular season just 2 weeks away, pitchers are lengthening their starts and adding curveballs to the mix. Promising, but lamentably green prospects are being reassigned to Triple A. And word has it that Mariano Rivera is preparing to throw an inning or two, just to be sure his 4-seamer is game-ready before opening day.

People have said that Baseball is Life. That may be stretching it for folks not named Yogi, but surely the game holds lessons for us all…even health policy wonks! Before we highlight the top submissions to this week’s HWR, let’s review some of these lessons:

Lesson 1: People Will Believe Anything
Somewhere this spring, a local sports writer opined that the kid who touched 98 in the 6th inning of a Cactus League game is the next Tim Lincecum, even though he has never recorded a regular-season out above Double A. Another said this year’s Phillies’ rotation will match the prodigious ‘71 Orioles quartet of Cuellar, McNally, Palmer and Dobson. Others claimed that A.J. Burnett will win 20 this year, and that Vlad Guerrero (whose gait is reminiscent of the Tin Man in Wizard of Oz) will steal 20 bases.

And people believe it!

During the epic health reform debate of 2009-2010, Democrats tried to include provisions which authorized payments to physicians for time spent helping Medicare patients prepare living wills. But Sarah Palin claimed those provisions allowed the government to create “death panels,” and John Boehner warned that they would “start us down a treacherous path toward government-encouraged euthanasia.”

People believed that, too!

To this day, an astounding 30% of elderly Americans believe the new health law empowers government panels to make end-of-life decisions for Medicare beneficiaries.

Lesson 2: Sometimes You Get a Do-Over, Sometimes You Don’t
Umpire Jim Joyce robbed Tigers pitcher Armando Galarraga of a perfect game last year when he blew a call on what should have been the last out of the game. Although Joyce later admitted his mistake, there are no do-overs in baseball. The pitcher’s chance to make history was gone forever.

Meanwhile, GOP-appointed Federal District Judge Robert Vinson decided in January that since he found one provision of the Big O’s health law to be unconstitutional, he might as well trash the whole deal. The decision threatened to disrupt planning in 50 states and confused the bejesus out of the American public. But unlike baseball, the US judicial system does permit do-overs…sort of. Two weeks ago, Vinson issued a stay of his own ruling, effectively allowing the law to stand pending an appeal to the Supreme Court.

Galarraga would be immortal if Joyce could have done that!

Go figure. Anyway, the Yankees will rise again in 2011 (believe me!) and finally, thanks to the HWR All-Stars who contributed posts for this week’s edition. Here is the formidable line-up:

The Sluggers (Health Policy)
For his post on the Forbes website, Avik Roy produced a chart showing results from the Health Tracking Study Physician Survey. The chart confirms that physicians refuse to accept Medicaid patients at rates that far exceed those who are covered by Medicare and private insurance. Roy suggests this problem is responsible for poor clinical outcomes seen in Medicaid beneficiaries.

Between innings, Roy should have a beer with Austin Frakt, who pretty much blows-up the premise that Medicaid recipients receive poor quality health care. In a post for the Incidental Economist, Frakt shows that studies used to support the premise reveal an association between Medicaid and individuals with poor health… it’s their poor health, Frakt says, that is driving poor outcomes in this population, not lousy doctors or poorly designed care systems.

Now that President Obama has decided to support Wyden-Brown, disaffected governors and state legislators can craft PPACA alternatives that are more to their liking, writes Joe Paduda over at Managed Care Matters. According to Paduda, if Republicans actually have a better approach to the problems of health care access and cost, they are going to win big in 2012.

For his part, John Goodman predicts that the PPACA will encourage many patients and providers to opt-out of the third-party payer system. Posting on his own Health Policy Blog, Goodman visualizes a major shift toward concierge-type services and the creation of new markets in which providers compete for patients on price, quality and amenities.

Neil Versel is a huge fan of Don Berwick, but he deplores the way President Obama attempted to install the Quality Don as a recess appointment to head CMS in July, 2010. According to Versel, the underhanded nature of the appointment provided fodder for “uninformed ideologues and assorted nut jobs to attack Obama’s healthcare reform efforts.” Versel’s blog is Meaningful HIT News.

Over at BNet Healthcare, Ken Terry observes an accelerating trend in which insurers and providers are partnering to create Accountable Care Organizations. Terry believes the 2 groups actually can cooperate to form such organizations, and cites several recent acquisitions and partnerships which appear to support his position.

Marsha Gold has followed the Medicare Advantage program and its predecessors for years. In her post on the Health Affairs Blog, she summarizes the program and describes how its beneficiaries will be affected by the PPACA.

In a post for his Health Business Blog, David Williams reminds us that many folks want to overturn new rules restricting Flexible Spending Accounts. Williams ups the ante a bit by suggesting that we eliminate FSAs altogether, and get rid of those pesky tax deductions for health insurance while we’re at it.

David Kindig reviews the implications of Wisconsin Governor Scott Walker’s plan to eliminate the state’s $3.6 billion dollar deficit. Kindig argues that some of Walker’s proposed cuts (including reducing Medicaid eligibility) will have serious health implications for people in his state. His post appears at Improving Population Health.

The Lucidicus Project’s Jared Rhoads reacts to presentations he heard at the TEDxDartmouth 2011 conference. After hearing Al Mulley’s familiar argument that our health system needs to adjust more effectively to consumer preferences, Rhoads doesn’t believe we can pull it off.

Reconciling state and federal laws can be difficult, and according to Louise Norris of the Colorado Health Insurance Insider, Health Reimbursement Arrangements (HRAs) are a particularly nettlesome case-in-point in her home state. Her post clarifies the situation, thankfully.

The Starters (Providers)
Roy Poses describes how physicians who are employed by corporations can be pressured to put the corporations’ economic interests ahead of their patients’ interests. Writing for Health Care Renewal, Poses argues that the primary means of corporate control includes restrictive covenants in contracts that have been signed by naive physicians, or signed by physicians under duress.

The PPACA will eventually generate a huge increase in the number of ER visits, according to Amer Kaissi. He argues that better coordination between ER and primary care doctors will be required to address the coming deluge, and offers a roadmap for this effort. Kaissi posts on Healthcare Hacks.

Julie Ferguson of Workers Comp Insider writes that nurses, nurses’ aides and paramedics are facing a rising tide of on-the-job violence. In fact according to Ferguson, only police and correctional officers experience higher rates of on-the-job assaults. Ferguson explores whether this is emblematic of a dysfunctional health system or just a sign of the times.

Liz Borkowski reminds us that while palliative care teams can reduce costs associated with the care of seriously ill hospitalized patients, most people who are eligible for these services don’t receive them. Borkowski, who posts at The Pump Handle, concludes that we have to do more to encourage utilization of these teams.

On The Health Care Blog, Matthew Holt posts an interview with JD Kleinke concerning the latter’s new novel, Catching Babies. Holt describes the book as a “tour de force of health policy and medical soap opera–Health Affairs meets Grey’s Anatomy–wrapped up in the complex world of childbirth.”

The Closers (Quality and Safety)
There is limited evidence to support claims that pay for performance programs improve quality and reduce the costs of health care, according to Jason Shafrin, who posts on The Healthcare Economist. Shafrin reviews Massachusetts’ pioneering P4P program and several other ones that failed to improve care.

Jaan Sidorov laments that a one-size-fits-all approach to health care—characterized by guidelines and decision support—is woefully behind sociotechnical trends that make “mass personalization” possible. Writing for Disease Management Care Blog, Sidorov argues that those who embrace the latter approach (by tailoring treatments based on the health status, preferences and values of individual patients, for example) will win in the marketplace.

At The John A. Hartford Foundation Blog, Chris Langston discusses the problem of overmedicating the elderly. He reviews a study in which 42% of the Indiana Medicaid population who live in nursing homes received at least one “potentially inappropriate medication.” Not surprisingly, these patients had worse health outcomes.

-Seventh Inning Stretch-
Famed HWR Contributor Argues Against a Key Policy Decision:


The Base-Stealers (Health IT)
Many CEOs and CIOs believe that their healthcare IT systems are secure because they “use SSL encryption” or “have a firewall.” That’s not the case, according to The Healthcare IT Guy, Shahid N. Shah. Shah offers a list of questions that executives can use in order to assure their systems really are secure.

Walking through the palatial vendor displays at this year’s HIMSS conference, Anticlue blogger Elyse Nielsen heard surprisingly little buzz about “the cloud.” In her post, Nielsen explains why this was the case, and opines that it won’t be long before the buzz picks-up.

The Slick Fielders (Pharmaceuticals)
Over at Nuts for Healthcare, Jeffrey Seguritan wonders what things would be like if drugs and their makers were forced to endure the same mano-a-mano competition that makes the NCAA basketball tournament such a good watch. Although the FDA does not require comparative trials like this before green-lighting drugs, Seguritan reviews a few such trials that are actually underway.

The Five-Tool Guys (Media)
Lately, health media watchdog Gary Schwitzer has focused on instances in which press releases drive what we call “news” in health care. In a pair of posts on his HealthNewsReview Blog (here and here), Schwitzer warns that when this happens, independently vetted journalism may not have taken place. 

The Stud Prospects (Consumerism)
Employers and health plans continually seek ways to contain health care costs. According to Dave Kerrigan, limiting the size of provider networks is a powerful and potentially beneficial tool in this regard. Kerrigan’s post appears on A Musing Healthcare Blog.

The Rabid Fans
Nobody is immune from DrRich’s sharp-tongued post on The Covert Rationing Blog. DrRich skewers, in no particular order, lying doctors, the right-wing media, the left-wing media, and quite possibly my Aunt Millie as well. We’re not sure what DrRich is for, but we know what he’s against, and it’s just about everything.

“Unions get waivers,” the InsureBlog’s Bob Vineyard exclaims. “Campaign contributors get waivers. Business owners and states get waivers. Why should consumers be left out?” In his post, Vineyard points out that some Michigan Representative wants to give consumers the right to opt out of “Obamacrap.” Obamacrap? Really? Obamacrap?

Whatever. Two weeks from today, Jason Shafrin hosts the Health Wonk Review over at the Healthcare Economist. Good luck Jason, and thanks to the all-stars who contributed to today’s edition!


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The Prescribing Fiesta for Atypical Antipsychotic Drugs

February 3rd, 2011 | No Comments | Source: MedPageToday

When the so-called “atypical antipsychotic” drugs became available for the treatment of schizophrenia, physicians began prescribing them like crazy because they did not cause debilitating extrapyramidal side effects like their predecessors. As we described previously, relentless and occasionally unscrupulous marketing campaigns by drug makers also drove utilization of the newer agents.

Unfortunately, the atypical agents turned out to have a nasty side-effect profile of their own. They promote obesity and diabetes, increase the risk of cardiovascular events, precipitate tics and increase mortality in elderly patients with dementia, among other things.

The weight gain/diabetes problem is particularly severe in children—a demographic in which these agents are rarely indicated. In one study for example, the drugs caused youths between the ages of 4 and 19 to gain between 10 and 19 pounds on average in just 11 weeks.

What’s New?
Recently, G. Caleb Alexander and colleagues at the University of Chicago reviewed historical trends in the use of atypical antipsychotics and published their findings in Pharmacoepidemiology and Drug Safety. It’s a largely confirmatory study, and the picture they paint is not pretty.

Caleb’s team queried nationally representative data from IMS Health’s National Disease and Therapeutic Index to characterize prescribing behavior for antipsychotic drugs in outpatient settings. (more…)


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Screening CT Scans Reduce Lung Cancer Mortality. A Little. Now What?

November 8th, 2010 | 2 Comments | Source: Commentary

According to the results of a large study, chest CT scans performed annually as a lung cancer screening test can reduce the risk of lung cancer death by 20% in current and former heavy smokers.

To reach these conclusions, federally funded scientists performed a multi-center trial in which they enrolled 53,000 people between the ages 55 and 74 that had at least a 30 pack-year history of smoking. Participants were randomized to receive either a chest x-ray or a CT scan at trial entry and then again one year, and 2 years thereafter. Ex-smokers that had quit within the last 15 years were enrolled as well.

The enrollees were followed for up to 5 years. There were 354 lung cancer deaths in the group that was randomized to receive CT scans, and 442 deaths in those receiving chest x-rays. The difference was large enough to prompt the study’s overseers to halt the study before its planned completion date, and to publicize the findings even before the write-up appeared in a peer reviewed journal.

Lung cancer kills nearly 160,000 people per year in the US. That’s more than the combined annual deaths from breast, colorectal, prostate and pancreatic cancers combined. 

Previous studies had ruled-out chest x-rays as useful screening tests for the scourge, because they caught the disease too late. Not surprisingly therefore, many scientists hailed the news as a major advance in lung cancer screening.

“This is the first time that we have seen clear evidence of a significant reduction in lung cancer mortality with a screening test in a randomized controlled trial,” the National Cancer Institute’s Christine Berg told the New York Times.

Statements like this seem premature to me. Chest CT scans cost between $300-1,000 per test. There are nearly 90 million Americans who smoke or used to smoke. A widespread screening program using this technology would cost tens of billions of dollars per year in direct costs alone.

That’s not counting the indirect costs. In the present study, fully 25% of the subjects who were randomized to receive a CT scan were found to have a false positive result (an abnormality that turned out not to be cancer). Many of these false positive results undoubtedly triggered additional scans, lung biopsies and even thoracic surgery which drive up the overall costs of the screening program many times over.

It’s not clear that our overburdened health system can accomodate the cost escalations implied by a widespread CT scan-based screening program for lung cancer.

Beyond this, CT scans, even the newer “Spiral” scans, are associated with modest levels of radiation exposure in their own right. The cumulative effects of this can actually cause cancer.

And that 20% mortality reduction? That statistic can, in itself, be deceiving. According to Jaan Sidorov’s calculations over at Disease Management Care Blog, the absolute cancer death percentages in last Friday’s study were 1.3% for subjects receiving the CT scan and 1.7% in those receiving chest x-rays. The absolute difference in death rates was therefore about 4 in a thousand. More than 98% of both groups didn’t die of lung cancer during the study period, and the direct cost per life saved was $180,000. That’s an awful lot of CT scans, and an awful lot of money to achieve that reduction in absolute risk. (more…)


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Docs Push Back Against Performance Reports

August 24th, 2010 | No Comments | Source: Wall Street Journal

Private health insurance companies have long since required patients to pay higher out-of-pocket fees when they see physicians who are not in the insurers’ contracted physicians network. In a more recent development, they have begun to rank physicians according to quality and cost parameters and offer enrollees lower out-of-pocket charges if they see physicians who fare better on these parameters.

In such programs for example, a doctor shown to order fewer imaging tests that are of questionable value would rank in a higher category.

Physicians have always objected to these practices. A March article in the New England Journal of Medicine brought the issue to a boil by showing that these tiered rating systems misclassified 22% of all doctors.

The study prompted provider organizations to release a letter protesting the payer’s practices. “Physicians’ reputations are being unfairly tarnished using unscientific methodologies and calculations,” the letter claimed.

“There are serious flaws in health insurers’ programs to try to rate individual physicians,” AMA President Cecil Wilson added in an interview with the Wall Street Journal.

The provider organizations implored payers to reevaluate their ranking programs.

Payers’ reactions to the letter were lukewarm. For example, Cigna told the Journal that its doctor-rating program already addressed issues raised in the study by focusing on physician groups rather than individuals. Besides that, “Some physicians do provide higher-quality or more-efficient care, and it makes sense to provide modest incentives for choosing that care,” said Dick Salmon, the company’s VP for network quality.

A spokesperson for WellPoint responded it has “taken a thorough, thoughtful approach in introducing measures of physician quality and cost effectiveness” and that the effort is “collaborative with the physician community.”


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US News Hospital Ratings Largely Subjective

June 28th, 2010 | No Comments | Source: Annals of Int'l Medicine, Medscape

US News & World Report’s influential “top 50” list of US hospitals is driven by subjective reputations of the institutions rather than objective measures of hospital quality, according to a study by Ashwini Sehgal of Case Western Reserve University.

scientificratingsystemTo establish subjective reputations of US hospitals, US News surveys 250 board-certified physicians from around the country. US News also uses objective data including nurse-to-patient ratios, availability of specific medical technology, risk-adjusted mortality for Medicare patients, and teaching status.

In analyzing the relative contributions of subjective vs. objective measures in determining which hospitals made the coveted list, Sehgal “found little relationship between rankings and objective quality measures for most specialties.”

Specifically, he found a strong correlation between a hospital’s rank in the US News list and the hospital’s “reputation score” as measured in the survey. By contrast, a hospital’s rank was variably correlated with the objective scores used by US News.

For example, the top five heart and heart-surgery hospitals based on reputation score alone were the same as those of the US News top five heart hospitals (Cleveland Clinic, Mayo Clinic–Rochester, Johns Hopkins University, Massachusetts General Hospital, and the Texas Heart Institute).

“Because reputation score is determined by asking approximately 250 specialists to identify the five best hospitals in their specialty, only nationally recognized hospitals are likely to be named frequently,” Sehgal told MedScape. “Users should understand that the relative standings of US News & World Report’s top 50 hospitals largely indicate national reputation, not objective measures of hospital quality.”

“Being well-known may be the result of many factors that are unrelated to the quality of day-to-day care,” commented Harlan Krumholz of the Yale University School of Medicine.

The write-up is in the Annals of Internal Medicine.


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