Archives for posts with tag: healthcare

Recently I learned about a pregnancy in which the woman was having frequent painful contractions. Only after her eventual delivery was it clear that she had developed a “uterine window,” where the scar from a previous C-section was almost worn through. The woman was told, after her Caesarian, there had been a significant risk of uterine rupture.

But why then was she not delivered earlier? Because, answered the doctor, there are risks to the baby from preterm delivery.

In that case, what was the balance between the risk of uterine rupture on the one hand and the risk of preterm delivery on the other? No one seemed to consider this tradeoff, or at any rate discuss it with this woman. She kept reporting her contractions; she was reassured and pain relief was provided; but preterm delivery was never considered, as if 39 Weeks were carved somewhere in marble.

Such hidebound protocolism is the norm across medicine. The blood pressure must be lower than 140 over 90, because…, well, because guidelines! The hemoglobin A1C must be lower than 7 because the American Diabetes Association said so, because…they are the experts!

Of course, those who recommend these cutoffs are experts. But that does not mean there are never any countervailing concerns or other possible routes. Is there a way to flip the protocol switch to “flexible” in doctors heads?

Another problem with implementing healthcare standardization on a large scale is that there’s no possible way of judging empirically whether it will all work. (Standardization is the question here. Other issues are easier. For example, I think it’s uncontroversial at this point that expanding healthcare access will save lives.) Neither is there an experimental design which could test the question. We basically have to take it on faith that checklists will scale up to entire healthcare systems.

Is there a way to foresee problems when large systematic change like this is undertaken – in any field, not just medicine? I am asking you, dear readers, because it’s frankly something I haven’t looked into much. Did anyone say, wait a minute, we shouldn’t construct a huge network of interstate highways? Or: let’s think a minute before we build and test an atomic bomb?

There are instances where people did stand athwart history and yell  Stop. Iraq comes to mind. But political change, war and peace, seems different, more reactive, than systematic change which we try to initiate on an a priori basis.

Of course, I don’t think healthcare standardization is per se dangerous. I just think, per  my previous post, that much of what’s worthwhile in healthcare is not currently quantified. Not unquantifiable as I said before, but currently understudied. Do we know enough about what will be left behind if we move forward under our current, imperfect assumptions about quality?

Atul Gawande is a technophile and a believer in the checklist, and he yokes these ideologies to an attractive metaphor in his newest essay for the New Yorker. The article is worth reading in its entirety, but it can be easily paraphrased. The Cheescake Factory, like other successful restaurant chains, has “brought chain production to complicated sit-down meals.” They’ve done it by far-reaching standardization of the best possible processes – but not all the way down, since some freedom is left for the front-line practitioners, for example, the line cooks, to get the job done according to their personal practices. Flexibility is built into the restaurant’s practices, which change regularly according to new data. And customers are satisfied. 

Health care in the United States, on the other hand, does none of this currently. Practices are incredibly diverse, often for no good reason. Particularly touching – as in so many of Gawande’s articles – was a story that he elicited from a Cheesecake Factory employee, Dave Luz, a Cheesecake Factory regional manager in the Boston area. Luz’s mother, aged 78, had a fall and was subjected to the depressingly normal dysfunctions, malfunctions, miscommunications, and screwups of an American hospital. And, when it was time for her to go home, no one coordinated anything. It was up to Luz to do everything, even get her dressed.

An aide was sent. She was short with him and rough in changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if there were a video camera in here, you’d be on the evening news.’ I sent her out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It was unbelievable.”

A terrible story. Gawande concludes eventually with a not unexpected conclusion. Standardization should change American medicine. Best practices do not make it down to the medical equivalent of the line cook. Doctors bristle at being told to do things better. “Already, there have been startling changes,” Gawande reports with excitement. “Big Medicine is on the way.”  

He tips his  hat to the obvious objections. Are we ready to make medicine into Walmart? What about accountability and transparency? “Some will see danger in this. Many will see hope. And that’s probably the way it should be.”

But one problem doesn’t make its way into the article in more than dribs and drabs. Does it work? Does massive standardization do the trick? Of course, we know that checklists work wonders in the critical care setting (from which Gawande presents most of his anecdotal evidence). 

But in nearly every other area of medicine, people are still hotly debating whether standardization, or as Gawande puts it, quality control, makes people less sick or helps them live longer. Does giving antibiotics within a specified timeframe actually keep people from dying from pneumonia, or increase the unneeded use of those medications? On a larger scale, do the incentives provided to accountable care organizations actually improve care?

There’s an even deeper problem. What do we do about the majority of medical concerns for which there is no standardization? What happens when clinical judgment, often based on little more than anecdote, meets patient preference? Perfecting the mashed potato tower and slicing the avocado to a quarter of an inch is perhaps quite like fine-tuning the ventilator settings or turning down the oxygen. Critical care involves many quantifiable judgments. But what about all the non-quantifiable judgments?

And what about all the parts of medicine which are not strictly quantifiable? That aide who manhandled Luz’s mother: what standardization would have kept that person from acting like a jerk? Employees are only as good as the organization hiring them, but human beings act only as humanely as their capacity for compassion allows. The technophile’s faith will always let him believe in the perfect cheesecake in the next concession over. But the astute skeptic, the careful consumer of metaphor will realize that sometimes a patient is a patient, not a dish off the menu. 

What is your preferred quality domain, all things being equal?

Answer Votes Percent
Effectiveness 8 47%
Patient-centeredness 4 24%
Equity 2 12%
Safety 1 6%
Timeliness 1 6%
Efficiency 1 6%

It wasn’t a big poll, but I find the answers interesting. I asked you what the most important quality domain was. There’s nothing statistically significant here, because only 17 of you responded. (If this was just 1 person responding 17 times, let me warn you that the punishment for screwing around is severe and swift. This is a serious blog.)

What catches my eye are the several choices that lost out and ended up at the bottom: safety, timeliness, and efficiency. It could be that people didn’t really understand what these meant. (Timeliness – that medical care be delivered at the right time, i.e. neither too early nor too late; efficiency – that resources not be wasted, or underutilized, in delivering the care.) 

Safety, though, is surely something that everyone understands. Why didn’t it get more votes? There’s no clear answer from this unscientific effort, but here are some speculative possibilities:

It’s something everyone assumes already exists, until they are themselves affected by subpar safety. Who judges an airline or a car by its safety record? Maybe we don’t talk about those things because we assumed that someone, somewhere, is ensuring the safety of our airline travel or automobile  manufacture. Certain people, by pointing out governmental and private negligence, have forced us to pay attention to things we might not want to notice. The same is true of healthcare, but maybe that just hasn’t registered yet.

Or perhaps, subconsciously at least, the category “effectiveness” already folds in safety. If we are delivered quality care, we already assume that it will be done without errors – certainly without serious error. If our gall bladder were removed without a trace but then we got a blood clot in our leg, we might not consider that an effective cholecystectomy!

However, apart from our individual preferences, the real reason I put up this poll was to illuminate a larger problem. There is precious little research on what patients think is meant by high-quality healthcare. If we make use of new public reporting mechanisms (or reporting done by private concerns, like Consumer Reports) to tell us which doctors or hospitals are better, we should make sure that we understand and agree with the criteria.

As was said in the report Crossing the Quality Chasm [blah blah blah]….

Every report and article on the topic “health care quality” starts this way, because the report was groundbreaking, laying out the domains that we should aspire to perfect: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. These domains apply at multiple levels throughout the healthcare system. But as Don Berwick pointed out, our true lodestone should be the patient’s experience.

In that case, why don’t we ask how people (sorry, “patients”) feel about these domains, and what are most important to them? Of course, it’s impossible to achieve all the domains perfectly at once. Everyone could be made perfectly safe if nothing were attempted. Care could be timely if no one ever asked patients’ opinions or double checked that errors weren’t being made. And so on.

How would you make the tradeoff, if you could? Once I get your answers, we can discuss how they compare to past and present literature, and what to do about the balancing act.

PS – you can pick up to 3 options in the poll.

A recent post on the Health Affairs Blog, Patient-Centered Care: What it Means and How to Get There, is a nice summary of the importance of a field that I happen to be involved in. However, some false notes are sounded and I think it’s worthwhile to correct them. [The blog itself appears to be down at the moment, or I’d comment there too.]

At a recent symposium concerning both saving money and improving patient care, Health Affairs Editor-in Chief Susan Dentzer stated, “It is well established now that one can in fact improve the quality of health care and reduce the costs at the same time.”  This is exactly the principle behind the growing movement toward patient-centered care.

First of all, I don’t think it’s very well established at all that improved quality can be made to co-exist with reduced cost. Certainly we hope that is true, but it doesn’t seem to be established yet. For example, a recent study of  pilot projects implementing Accountable Care Organizations — the great hope of cost-cutters, care organizers, and health policy wonks everywhere – found that they…didn’t save all that much money. Plenty of concern has already been aired that improved access – to care in general and preventive services in particular – will cost more on the front end, not less.

Second, I hope that the cost-cutting-and-care-improving “principle” isn’t the one behind any movement toward patient-centered care. Rather, I would hope that patient-centered care is a sufficient end in itself.

Moving on, towards the end of the post, there is a paragraph that throws me for a loop.

… Doctors practicing patient-centered care have systems in place to continually measure patient perceptions.  On-line tools are often used and questions are related to patient satisfaction and other care parameters.  Moore and Wasson, in their study, The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship, document improved patient satisfaction and education using a simple on-line tool. It is important to remember that patient-centered care revolves around continually questioning patients to assess their needs and the effectiveness of the care they are receiving.

If you follow the links, you get to a perfectly reasonable article from 2007 from the journal of the American Academy of Family Practice, which includes a on-line tool to help patients organize their care. However, the placement of this link in the paragraph implies that this is the “system[] in place to continually measure patient perception.” As I pointed out in a earlier post at KevinMD, the only “system” in wide use are Press-Gany and CAHPS surveys, which tend to be mail-based, have poor response rates, and measure “patient perception” in only a limited number of domains.

So with regard to making patient-centered care a matter of prime institutional importance and real-time reporting, we still have a way to go. As large academic institutions like mine make their way towards unified EMRs, implementing measures of patient perceptions – no, not just perceptions, but actual patient-centered care – will be an important part of the change, if we can make it happen.

She spoke on health literacy – what it has achieved and what next needs to be done. There is a consensus, she says, that decreased health literacy leads to poorer health outcomes, and that materials in a variety of settings – and in society at large – are not matched to the health literacy of individuals. Health literacy is poor in a number of industrialized nations. Despite these research findings, and consensus as to need, policy and standards of best practice have not yet redressed the balance. She adduced three domains of health literacy that R. Nutbeam, from Southampton, has proposed – functional literacy, interactive literacy, and (a new domain) critical literacy, the ability to participate in discussions of policy and change. As foundation for these various domains, she referred to theoretical works by Kurt Lewin (who invoked “force fields” and the removal of barriers) and Paolo Freire, who believed in the silenced individual as the master of their domain (cf. public health efforts to match, e.g., parasite eradication efforts to individuals’ knowledge of their own worlds). She concluded with a call to action on the fronts of policy, research, practice, and advocacy, while forecasting the merging of several branches of research (communication, culture, and literacy).