What do top hospitals have in common? Not as much as you think.

What do top hospitals have in common? Not as much as you think.

Researchers at the Atlas looked at how the top 23 academic medical centers, as ranked by U.S. News and World Report, provide care to their patients. Their results show huge variations in how the very best hospitals care for their sickest patients.

A patient at New York Presbyterian Hospital can expect to spend 20 days in the hospital during the last six months of life. The average Mayo Clinic patient would have 10 days in the hospital over the same time span.

At the University of Utah, the average patient sees 20 doctors during the last six months of life. At the Cedars-Sinai Hospital in California, that number is 73 physicians.

A patient at UCLA’s Ronald Reagan Hospital is three times as likely to have a fall or injury while in the hospital than one at Cedars Sinai, also in Los Angeles.

“We know these differences cannot be explained by the prevalence of diseases,” Goodman says. “Yes, populations differ. Those are small differences we see compared to the dramatic differences in care.”

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’Informed Decision’ May Irk Surgeons as It Cuts Costs - HealthLeaders Media

’Informed Decision’ May Irk Surgeons as It Cuts Costs - HealthLeaders Media

But consider just a few recent headlines to see the paving of the large runway that may enable this plane to take off.

• A New York Times story last week revealed some 1,200 patients underwent unnecessary invasive cardiology procedures in one South Central Florida hospital, and many other facilities in the large HCA chain are under federal investigation.

• A Grand Rapids surgeon's study in September's Journal of Clinical Oncologysays far too many patients undergo unnecessary surgery to remove tumors in patients with advanced colon cancer when chemotherapy and a drug have a better success rate.

• A report in the New England Journal of Medicine found many women with breast cancer are unnecessarily undergoing a second surgery to remove more tissue for wider margins.

National blindspot

Some surgeons themselves think this is an idea whose time has come.

"We have a major national blindspot, and that blindspot is unnecessary medical care, and there's a ton of it that goes on," says Martin Makary, MD, a gastroenterology surgeon and researcher at Johns Hopkins School of Medicine.

Makary is the author of an upcoming and extremely controversial book, Unaccountable, about dangerous practices that persist in a culture that is allowed to hide its mistakes. He tells me that preliminary results of his research project reveal that when asked, surgeons think the amount of unnecessary surgery that hospital culture chooses to ignore is huge, "in the ballpark of 10% to 20%."

These are the big drivers of cost, Makary says. " [They are] big ticket items, like coronary artery bypass graft surgeries, colectomies, hysterectomies, and back surgeries. They not only have the biggest price tags, but they also have the highest complication profiles of anything we do in healthcare."

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Prostate Cancer Screening: What We Know, Don't Know, and Believe

Prostate Cancer Screening: What We Know, Don't Know, and Believe

Overdiagnosis makes screening seem to save lives when it truly does not (6). Cases of overdiagnosed cancer fulfill histologic criteria for cancer, but are not destined to progress and kill within the patient's natural lifetime. Yet, when detected through screening, these tumors are commonly treated, exposing patients to the harms of treatment without any true associated benefit. The man with such a cancer often believes that screening and treatment saved his life, but he would have been just fine had the cancer never been detected and treated. Overdiagnosis also increases the proportion of patients surviving 5 and 10 years. Lead-time bias increases apparent survival rates. Because screening diagnoses some patients earlier, they live longer after cancer diagnosis, even though they do not live longer than counterparts with similar cases of cancer that were not screen-detected. Overdiagnosis was known to be an issue in prostate cancer well before screening became popular. In the 1980s, the respected prostate cancer expert, Dr. Willet Whitmore, said that the quandary in prostate cancer is, “If cure is necessary, is it possible, and if cure is possible, is it necessary (7)?”

The screening literature stresses a difference between mass screening, in which large numbers of men are tested at an event, and screening within the physician–patient relationship. Much of my own concern about prostate cancer screening has been with mass screenings that mislead men to believe that screening can only help them. Over the past 20 years, celebrities, athletes, politicians, and prostate cancer survivor groups have endorsed screening. Mass screening is commonly conducted in shopping malls, churches, and community centers; at conventions and state fairs; and even in vans parked in grocery store parking lots. Hospitals, medical practices, fraternities, politicians, radio stations, television channels, and even an adult diaper manufacturer have sponsored mass prostate cancer screenings. Promotions for these events frequently discuss the high proportion of men with screen-detected tumors surviving 5 years and sometimes claim that screening saves lives. They never mention the potential harms of screening. Many well-meaning persons have supported screening activities and chose not to listen or believe those who have urged caution about screening. Mass screening is also a lucrative business. As Upton Sinclair once said, “It is difficult to get a man to understand something, when his salary depends on his not understanding it (8).”

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An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I'll bullet here, but you can go read on your own.

• Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
  Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
• First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
  There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
• Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
  Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
• We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
  In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
• For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs- cmhmd]
• Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
• Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
  Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

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How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

For many doctors, the malpractice case against a family physician named Daniel Merenstein epitomized how the broken medical liability system drives up costs. In 1999, Merenstein, then a resident, saw a 53-year-old man for a routine checkup and discussed with him the dubious value of a blood test to screen for prostate cancer. Since the test leads to many false positives and pointless treatments that can cause impotence and other harm, neither the American Cancer Society nor U.S. Public Health Service support its routine use. Presented with the data, the patient chose not to get the test.

When the man later developed prostate cancer, he sued Merenstein and the residency training program and ultimately won $1 million. According to the plaintiff's attorney, the doctor should have ignored the evidence-based national guidelines and not even have given the patient the choice to refuse the test.

This is the same story told on This American Life last month, and it is quite disturbing. In my "to-do list" for health care reform, medical liability reform is relatively low on my list*, but this story gives me pause.

I hope we can address this and make following guide lines in good faith a reason to dismiss a lawsuit. For more information on guidelines and Comparative Effectiveness Research in action, go here.

*Caps are not even on my list, but there are many other things we can do that benefit patients AND physicians, as outlined in this Slate article, and by the AMA.

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TIME - A Healthier Way to Pay Doctors

From Time Magazine

With the effort to rein in health-care costs increasingly framed as an unhappy trade-off in which insurers either slash benefits or raise premiums, some in Washington are beginning to ask a question long considered off-limits: Do we simply pay doctors too much?

The truth is, we pay them all wrong.

Doctors themselves could tell you that — particularly primary-care providers (PCPs), the foot soldiers of the U.S. medical system. New doctors graduate from medical school lugging up to $200,000 in student loans. Paying that off takes a big bite out of even a low-six-figure salary. Add to that the high costs, long days and billing headaches involved in running a practice, and it's no wonder so many family docs are trading up to specialties like orthopedics or neurology, where the pay can be three times as great and the hours a whole lot shorter. Only 3 out of 10 doctors in the U.S. now are PCPs, compared with 5 out of 10 elsewhere in the world. Those family physicians who remain find themselves in a constant money chase, meeting their monthly nut with the help of the revenue they make by prescribing tests — X-rays, CT scans, EKGs — that may or may not be strictly necessary but generate a lot of separate billing.

--------

In his Sept. 9 speech to Congress, President Obama singled out Geisinger and Utah's Intermountain Healthcare as examples of organizations that are learning to do things right. He could have cited others too: the Cleveland Clinic, the Mayo Clinic, Kaiser Permanente. What these providers have in common are the creative ways they're doing away with fee-for-service and replacing it with an imaginative mix of systems that cost less, keep patients healthier and make doctors happier. "We need a transition to rewarding the actual value of care," says Dr. Elliott Fisher, director of population health and policy at the Dartmouth Institute. "For now, our payment system is getting in the way.

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Doctor Self-Referrals Part of Health-Care Cost Trend - washingtonpost.com

Doctor Self-Referrals Part of Health-Care Cost Trend - washingtonpost.com:

"In August 2005, doctors at Urological Associates, a medical practice on the Iowa-Illinois border, ordered nine CT scans for patients covered by Wellmark Blue Cross and Blue Shield insurance. In September that year, they ordered eight. But then the numbers rose steeply. The urologists ordered 35 scans in October, 41 in November and 55 in December. Within seven months, they were ordering scans at a rate that had climbed more than 700 percent.

"The increase came in the months after the urologists bought their own CT scanner, according to documents obtained by The Washington Post. Instead of referring patients to radiologists, the doctors started conducting their own imaging -- and drawing insurance reimbursements for each of those patients."

It is clear some oxen have to be gored, or at least hobbled, to "bend the curve." Let's start being explicit about where to do this. Private insurers, over-utilizing physicians, drug and equipment manufacturers and suppliers. Let's start the hard discussions, please.

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What the Mayo Clinic knows | Freep.com | Detroit Free Press

What the Mayo Clinic knows Freep.com Detroit Free Press:

Three goals underscore our nation's ongoing healthcare reform debate: 1) insurance for the uninsured, 2) improved quality, and 3) reduced cost. Mayo Clinic serves as a model for higher quality healthcare at a lower cost.

President Barack Obama, after referencing Mayo Clinic and Cleveland Clinic, advised: 'We should learn from their successes and promote the best practices, not the most expensive ones.' Atul Gawande writes in the New Yorker, 'Rochester, Minn., where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest 15% of the country -- $6,688 per enrollee in 2006.

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Do we do better in the US on prostate cancer?

Four Pinocchios for Recidivist Rudy - Fact Checker:

This is not about Rudy Giuliani, he's irreleveant, but this is about the mythology that remains in the World of Fox about poor outcomes elsewhere. Somebody brought this one up recently (prostate Ca) so I put this here for future reference.

"Let's begin by deconstructing the original Giuliani claim, featured in a campaign ad in New Hampshire. It rests on a crude statistical calculation by his medical adviser, David Gratzer, on the basis of a 2000 study by a pair of health experts from Johns Hopkins university. According to Gratzer, '49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and consequently, that just 43 percent survived.'

There are several problems with this line of reasoning, according to health experts.

In order to make statistically valid comparisons in epidemiology, it is necessary to track the same population. Because prostate cancer is a slow-developing tumor, it is probable that the Britons who died of prostate cancer in 2000 contracted the disease 15 years earlier. They represent an entirely different cohort of cancer sufferers than those who were diagnosed with the disease in 2000. The number of Britons diagnosed with the disease is itself a subset of the number of Britons with the disease.

'You would get an F in epidemiology at Johns Hopkins if you did that calculation,' said Johns Hopkins professor Gerard Anderson, whose 2000 study 'Multinational Comparisons of Health Systems Data' has been cited by Gratzer as a source for his statistics. 'Numerators and denominators have to be the same population.'

Five-year prostate cancer survival rates are higher in the United States than in Britain but, according to Howard Parnes of the National Cancer Institute, this is largely a statistical illusion. Americans are screened for the disease earlier and more systematically than Britons. If you are detected with prostate cancer symptoms at age 58 in year one of a disease that takes fifteen years to kill you, your chances of surviving another five years (until the age of 63) are obviously much higher than if your cancer is detected in year eleven, at the age of 68. Both Anderson and Parnes say that it is impossible, on the basis of the available data, to conclude that Americans have a significantly better chance of surviving prostate cancer than Britons.

Whether or not early screening actually reduces mortality from prostate cancer is the subject of much controversy among researchers, both in the United States and Europe. According to Otis Brawley, chief medical officer for the American Cancer Society, "at least 50 percent of men diagnosed with prostate cancer don't need to be treated. The problem is that we can't figure out which men need treatment, and which don't."

In an attempt to figure out if screening for prostate cancer does indeed save lives, the National Cancer Institute has been following 70,000 men since 1992, but has yet to a firm conclusion, Brawley said. Half of the men in the sample are being screened and the other half are not being screened. An August 2007 NCI report said it was still unclear whether "earlier detection and consequent earlier treatment" led to "any change in the natural history and outcome of the disease." Screening can lead to "over-treatment" which can in turn result in undesirable side effects such as erectile dysfunction and incontinence.

"This is getting completely ridiculous," e-mailed Giuliani spokesman Jason Miller. "You are still not getting it. The point the mayor has made is that privatized medicine is better than socialized medicine. If you can find one person who said they'd rather be treated for prostate cancer in the UK instead of the US, we'd like to meet them."

UPDATE WEDNESDAY 4:30 P.M.: Reader Jim Crowder asked an interesting question this morning, in response to Dr. Brawley's statement that at least 50 per cent of men diagnosed with prostate cancer "don't need to be treated." Crowder asked, "OK, If I am in the 1/2 group that would benefit by earlier treatment, wouldn't I rather be in the US and receive it? In fact I have received treatment."

I [Fact Checker] asked Dr Brawley to respond. Here is what he says:

We know that at least half of the screened and detected do not need treatment and any treatment they get can only give them side effects of treatment, including a 0.5% to 1% chance of death from treatment.We do not know that we benefit the other half who have a disease that is destined to disrupt their life by causing symptoms and in many death. Indeed some of our clinical treatment studies are designed to figure out whether we cure those who need to be cured.

Connecticut versus Washinginton State comparisons show that men in Washington State have a much higher risk of prostate cancer diagnosis and treatment and side effects of treatment, but have the same risk of death as men in Connecticut. In several papers, [including] one by me, this has been attributed to the higher rates of screening in Washington compared to Connecticut. Both have had the same decline in mortality rates.

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Attacks on Dartmouth Atlas Rebutted

Health Affairs Blog:

"[HA Blog]Editor’s Note: In the post below, Amitabh Chandra responds to criticisms of the Dartmouth Atlas and offers his vision of the lessons of the Dartmouth findings on variations in health care costs and practice styles. Watch the Blog tomorrow for a roundtable discussion on Atul Gawande’s New Yorker article on McAllen Texas and the policy implications of the Dartmouth work. Roundtable participants will include Robert Berenson, Elliott Fisher, Robert Galvin and Gail Wilensky."

I heard Sen. Judd Gregg this AM on CSPAN pontificating at the Budget Committee meeting on health care, fretting that any kind of health board would result in "control" of health care by "Washington". If it's staffed by people like Dr. Chandra, we'll be OK.

But, more to the point, he still lives in the DC bubble fantasy land where he thinks patients have control of their health care, and not the private health insurers. He worries about a board being formed to guide decision making by clinicians. I think this is absolutely critical to reigning in health care costs, though, as Dr. Chandra so clearly indicates, this is as complex a set of problems as we're ever going to face in our life times, so it will require multiple iterations of progress to get where we ultimately wish to go.

And that was another thing Gregg lamented: the complexity of the bill. If he wants straight-forward, then HR 676 is his bill. But I'm guessing a single payer system is a non starter for him. So, given that we're talking about 20% of the economy, it's gonna be a complex solution!

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Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans:

"The American Medical Association has announced its opposition to a public-sector health plan that would compete with private insurers. Why? Because the AMA fears that Medicare E (for everyone) might not pay some specialists as handsomely as private insurers do now.

"Why do private insurers pay more? Because they can pass the cost along to you and I in the form of higher premiums. Medicare E has no one to pass costs on to—except taxpayers. And taxpayers will already be helping to subsidize those who cannot afford insurance.

"Everyone agrees that primary care physicians are underpaid. Democrats in both the House and the Senate propose raising their fees, as does the Medicare Payment Advisory Commission (MedPac)---the group that might take over setting fees for Medicare. Moreover, the House, the Senate, President Obama and MedPac have made it clear that they do not favor the across-the-board-cuts called for under the sustainable growth rate (SGR) formula. Congress has consistently refused to make those cuts and President Obama did not include them in the 2010 budget that he originally sent to Congress. On that score, the AMA has nothing to worry about.

"Protecting Excessive Fees for Some Specialists’ Services

"So what does the AMA fear? That either MedPac or Medicare will trim fees for certain specialists’ services. Keep in mind that Medicare’s fee schedule has traditionally been set –and adjusted on a regular basis, by the RUC-- a committee dominated by specialists.( Private insurers then follow that fee schedule, usually paying somewhat more for each service.) I have described this group in the past: They meet behind closed doors. No minutes are kept of their meetings. They rarely suggest lowering fees—even though as technology advances, some services become easier to perform. MedPac has pointed out that a less biased group should be involved in determining fees—perhaps physicians who work on salary, and are not affected by Medicare’s fee schedule.

"There is good reason to suspect that the RUC has over-rated the value of some services.. MedPac has suggested taking a look at particularly lucrative tests or treatments that are being done in large volume. Often, this may mean that patients who don’t need the service are receiving it; if the procedure isn’t necessary, then, by definition, they are being exposed to risks without benefits. And in fact, experience shows that when high fees are trimmed, volume falls, suggesting that rich fees were, in fact, driving overtreatment."

There is more here about using medicare to "bend the curve," or reduce over-utilization, improve use of preventive services, as well as a discussion of how a Public Plan might besubsidezed, etc. well worth reading, particularly about subsidization.

I would only add that the title falls a bit short: The AMA, or rather, conservative physicians, are hardly the only group fighting significant change. The Health Insurance industry, despite conciliatroy noise, will be the big guns or long knives as this goes forward. And behind them will be Pharma, other device and equipment manufacturers, probably home health servicers, ambulatory care centers, and, for purely ideological reasons, all conservatives.

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The High Concentration of U.S. Health Care Expenditures

The High Concentration of U.S. Health Care Expenditures:

"Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount. Examining the distribution of health care expenses among the U.S. population sheds light on areas where changes in policy might bring about the greatest savings.

"Select to download print version (PDF File, 785 KB). "


Indeed, well run micro-systems that exist at Mayo, Cleveland, Geisinger, Virginia-Mason and others show us it's possible.

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Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

"Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

"In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:

I think it fits in well with the ethos described in Gawande's article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

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Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954

Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954:

"Background Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

"Methods We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

"Results Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

"Conclusions Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients' lack of awareness about hospice and misunderstandings about prognosis."

First, having these conversations with patients is the right thing to do for a multitude of reasons, not the least of which is our duty to help our patients weigh the benefits and burdens of medical treatment. The reduction of unwarranted suffering is hard to over estimate.

Second, imagine the economic impact of doing the right thing. No rationing, just having the appropriate conversations with our terminally ill patients.

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Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending - Interactives - Quality/Equality newsroom - Quality/Equality - RWJF

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending - Interactives - Quality/Equality newsroom - Quality/Equality - RWJF

The above link takes youto the interactive map that is kind of cool to look at and comare a few regions to see where yours falls.

The actual NEJM article is here. And here is the substantive part of the article (for me, anyway):

What's going on? It is highly unlikely that these differences in growth could be explained by differences in health. Marked regional differences in spending remain after careful adjustment for health, and there is no evidence that health is decaying more rapidly in Miami than in Salem.

The variations allow us to rule out two overly simplistic explanations for spending growth. First, "technology" is clearly an insufficient explanation: residents of all U.S. regions have access to the same technology, and it is implausible that physicians in the regions with slower spending growth are consciously denying their patients needed care. Indeed, evidence suggests that the quality of care and health outcomes are better in lower-spending regions and that there have been no greater gains in survival in regions with greater spending growth.1 Second, it is difficult to blame regional differences entirely on the current payment system, since all our evidence on regional growth comes from populations in the fee-for-service system. Other research has emphasized the role of managed care in moderating the growth of costs,2 but this story cannot explain the rapid growth in Miami, where roughly half of Medicare enrollees are covered by Medicare Advantage plans.

The causes must therefore lie in how physicians and others respond to the vailability of technology, capital, and other resources in the context of the fee-for-service payment system. A recent study by researchers in our group provides further insight.3 Using clinical vignettes to present standardized patient care scenarios to physicians throughout the country, the researchers found that physicians in high- and low-spending regions were about equally likely to recommend specific clinical
interventions when the supporting evidence was strong. Those in higher-spending
regions, however, were much more likely than those in lower-spending regions to
recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending.

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The Evidence Gap - British Balance Benefit vs. Cost of Latest Drugs - NYTimes.com

The Evidence Gap - British Balance Benefit vs. Cost of Latest Drugs - NYTimes.com

"RUISLIP, England — When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught.

“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London.

"If the Hardys lived in the United States or just about any European country other than Britain, Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. A clinical trial showed that the pill, called Sutent, delays cancer progression for six months at an estimated treatment cost of $54,000.

"But at that price, Mr. Hardy’s life is not worth prolonging, according to a British government agency, the National Institute for Health and Clinical Excellence. The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

"British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

"For years, Britain was almost alone in using evidence of cost-effectiveness to decide what to pay for. But skyrocketing prices for drugs and medical devices have led a growing number of countries to ask the hardest of questions: How much is life worth? For many, NICE has the answer. "

What a great piece. I've been hearing more and more about NICE lately, with this being the most visible publication on it.

As I've said elsewhere under the "Rationing" label, I would much rather have a fair, national or regional, system of objective analysis by scientists deciding on what care we offer to patients than the current method. The current method being everything for everyone all the time until we can peel the oncologists (sorry, guys! Others of us are guilty, too!) off the patient. Our current method also includes allowing Lilly to lobby for new reimbursement codes to pay for Xigris, or Zimmer to get Medicare to pay twice as much for a "women's" TKR and assorted other pieces of free market capitalism.

But the US' favorite method of rationing care, of course, is by income. Don't have it, don't get it.

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Practice variation links

Some tidying up of older but still interesting info about regional variation in healthcare:

The Dartmouth Atlas study in Acrobat:
http://www.dartmouthatlas.org/atlases/2006_Atlas_Exec_Summary.pdf

And an op-ed piece from Dr. Goodman about utilization/variation:
http://www.nytimes.com/2006/07/10/opinion/10goodman.html?ex=1156046400&en=2960abf359ef20a7&ei=5070

An article about 'off the chart' utilization of angioplasties in Elyria, Ohio:
http://www.nytimes.com/2006/08/18/business/18stent.html?hp&ex=1155960000&en=b81be5f43f98a99b&ei=5094&partner=homepage

And a lecture Jack Wennberg talking about Atlas:
http://www.dartmouthatlas.org/atlases/NYAM_Lecture.pdf

Cheers,
Chris

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