Quality

Productivity Measurement in the United States Health System

  • By
  • Joe Colucci,
  • New America Foundation
  • and Rick McKellar, Harvard Medical School, and Michael Chernew, Harvard Medical School
October 2, 2013

Improving productivity in health care is, unquestionably, among the most important challenges facing policy makers and health care systems. Advances in medicine have greatly improved lives over the last century and ideally will continue to do so in the future. However, medical care also consumes a rapidly increasing proportion of society’s time and resources. That trend has continued to the point that growth in health care spending is considered a drag on the remainder of the economy.

Productivity and the Health Care Workforce

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
  • and Thom Walsh, Dartmouth Center for Health Care Delivery Science
October 2, 2013

BBC: Overuse of Hysterectomies in India

February 7, 2013
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A BBC report from earlier this weeks makes it very clear: overuse of elective medical procedures is not just an American problem, or even just a developed-world problem. The report tells the story of women in a number of rural villages in India, where hundreds of women have been convinced, cajoled, and frightened into having hysterectomies they almost certainly didn't need.

The story suggests that the procedures are probably being done to make money for unscrupulous local doctors. The docs work in India's private medical system, but the public insurance program for the poor allows patients to see private physicians when they can't acces the public healthcare system. According to the story, the doctors often tell patients they have cancer and need an immediate hysterectomy--sometimes without even performing a biopsy, and without offering other, less invasive forms of cancer treatment. Unnecessary operations make money for the physician, but they're a huge financial burden for patients--and although the article didn't mention it, unnecessary treatments also expose patientsto needless risk of serious complications and death.

The Indian government is starting to react to the apparent epidemic of overuse. But in addition to fixing perverse financial incentives, it's important to consider the role informed and empowered patients can play in ensuring unnecessary treatments don't happen. The article notes that women find it hard to refuse a surgery that the doctor says they need right away. One young woman said she wasn't even able to discuss the surgery with her husband first. Fixing that rushed and insensitive process is crucial. Patients in rural India have just as much right to make their own decisions as patients in rural Indiana--and fortunately, there are effective tools to help them make those decisions. Even if the public medical system can't yet reach all parts of rural India, it might be possible for the government to make sure shared decision making and decision aids are available--that could save money, and help patients avoid unnecessary treatment.

 

UPDATE: Dr. Mohammad Zakaria Pezeshki, Associate Professor in the Department of Community Medicine at Tabriz Medical School in Tabriz, Iran, saw this post & responded with some good thoughts of his own. He points out that it's crucial to have decision aids in patient-accessible languages, and that opportunities to inform and engage patients are not limited to shared decision making. Check out the post and the rest of his blog, Earth Citizens' Health!

Should Jerry Brown Just Ignore His Cancer?

  • By
  • Shannon Brownlee,
  • New America Foundation
January 2, 2013 |

As California’s oldest governor, Jerry Brown has gone out of his way to demonstrate his vigorous good health, jogging around the Capitol and even challenging reporters to pull-up contests—which he won. Now that he’s been diagnosed with prostate cancer and begun radiation therapy, some news outlets seem to be experiencing a bit of schadenfreude, gleefully calling the 74-year-old governor’s diagnosis a “blow to his healthy image.”

Meningitis deaths could have been avoided

December 18, 2012
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This op-ed is co-authored by Jeff Borkan, Chair of the Department of Family Medicine at Brown University School of Medicine.

The media attention and Congressional investigation into the tragic epidemic of spinal meningitis in people who had injections for back pain has focused on unsanitary conditions at the compounding pharmacy that produced the medications. At last count 620 cases and 39 deaths have been confirmed in 19 states because the steroids used in the injections were contaminated with a common fungus. Yet remarkably little has been said about the underlying cause of this tragic outbreak -- the widespread overuse of an unproven procedure (epidural steroid injections) that put the contaminated steroids into the spinal cords of patients in the first place.

The procedure involves inserting a needle into the spinal canal, one of the most vulnerable parts of the human body, and then injecting steroids, which are supposed to reduce inflammation and allow the back to heal. Each year, more than 9 million Americans are treated with spinal steroid injections, and one study found that the number of Medicare recipients undergoing this procedure increased by 159 percent between 2000 and 2010.

How did steroid injections come to be performed so often? Patients assume that most medical treatments are supported by years of careful studies. They think any invasive procedure that might put them at risk of harm is performed only by trained and certified physicians with rigorous clinical oversight.

In the case of spinal steroid injections, nothing could be further from the truth. There is no widely accepted guideline for the use of epidural steroids, and the U.S. Food and Drug Administration has never specifically approved steroids for that use. There is scant medical evidence to show that the use of epidural steroids is any more effective at relieving back pain than routine, conservative care or even sham (fake) injections. There are many possible side effects of this procedure, and while the most serious complications are rare, they can be disabling or life threatening. Yet this unproven, risky treatment is routinely offered on an outpatient basis by physicians who have widely varying levels of training and expertise. While most of those physicians undoubtedly believe they are acting in their patient’s best interest, there is no escaping the fact that they are paid nicely for a procedure that takes only a few minutes to perform.

There's no doubt that regulators should go after the makers of unsafe medications. Slipshod manufacturing practices can't be tolerated when people's lives are at stake. At the same time, we need to rethink our willingness to pay for procedures and tests that have known risks and unknown benefits. Epidural steroid injections are just one of myriad examples of such treatments, and taken together, the overuse and misuse of medical procedures is costing us dearly, both in terms of wasted dollars and wasted lives. It’s time to build a health care system that serves patients rather than profits, and the first step is recognizing tragedies like the spinal meningitis outbreak for what they are, cases of overuse.

156 Questionable Procedures

December 10, 2012
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Australia's Medicare system took a big step toward cheaper and more effective healthcare recently by ordering a systematic compilation of procedures that are harmful, not supported by evidence, overused for a large number of patients, or of low value for some other reason. The list is based on recommendations from the British National Health Service's National Institute for Health and Clinical Excellence (NICE), evidence assessments from the Cochrane Collaboration, and other sources. The list is full of old favorites for people who pay attention to overtreatment--procedures like vertebroplasty, elective angioplasty for stable angina, PSA testing, and some arthroscopic knee surgeries. But it also includes a wide variety of specific surgical techniques and other, more technical examples of ineffective practices that we non-clinicians don't hear about or talk about as much.

It's hardly a complete list of all the ways patients get overtreated. The study didn't include pharmaceuticals, and lots of overtreatment is more the result of being in an overly-intense treatment environment (like a hospital or an ICU than the result of a specific decision to do a specific procedure. But it's certainly useful to see a good long list of ways that we can eliminate waste in the medical system--hopefully other systems outside Australia will take note, and groups like Choosing Wisely will take a look at the list, draw from it, and add their own examples!

The paper describing how the list was created is here; the full list is in an appendix to that paper, here.

Do Prestigious Residencies Mean Better Doctors?

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
November 13, 2012 |

Each fall, medical students in their fourth and final year select a medical specialty and apply to residency programs. Residency, which lasts anywhere from three to eight years, is run by teaching hospitals. It's when newly minted MDs learn the hands-on, practical skills of doctoring -- how to make diagnoses, perform surgeries, order and interpret tests, etc. They also learn how to deal with patients and families, and work with other caregivers.

Cancer Screening: Emotion vs. Data

November 1, 2012
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We've just closed out a month where everything from the White House to professional football players' cleats turned pink to raise awareness of breast cancer. Every year during October, there's a constant focus on raising money for breast cancer research, and on reminding women to get screened. The mantra is always, "Early detection saves lives."

As we've written before, it's an article of faith for many patient advocates and medical organizations that cancer screening is an unadulterated good. But a new study in the Lancet on breast cancer screening provides yet more evidence that while mammography can save lives, screening also causes serious harms. They find that for every woman whose life is saved, three other women will be overdiagnosed and face unnecessary treatment. That doesn't even count the harm caused by false positives on screening mammograms, which lead to unnecessary stress as well as biopsies and other tests. It's worth noting that the population in the Lancet study includes women over 50, in line with the US Preventive Services Task Force's recommendations. Expanding screening to women under 50 means that fewer of the women screened will have harmful cancers, so the harm of overdiagnosis is more likely to outweigh benefits from catching cancer early.

To go along with the Lancet study, the New England Journal of Medicine has a new Perspective piece by Drs. Steve Woloshin, Lisa Schwartz, William Black, and Barnett Kramer. They make a forceful argument against one-sided pro-screening campaigns that present the benefits of screening, while ignoring the harms. The piece is linked to a great slide show with some of the most egregious pro-screening advertizements.

When Patients — Not Doctors — Make Medical Mistakes

  • By
  • Shannon Brownlee,
  • New America Foundation
September 10, 2012 |

For most patients in the real world, getting good medical care involves complicated decisions. It’s not as simple as what often gets shown on TV, where a patient goes in, the doctor figures out what’s wrong, and then he performs some lifesaving surgery. Most of modern medicine, especially for the elderly, is a lot messier — usually there’s not “right” answer, no perfect treatment. And a patient needs to be an active participant in making choices in treatment.

For Your Thursday Enjoyment: Health Wonk Review!

August 16, 2012
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Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

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