There are a few themes that permeate this blog – the impact of new technology on medical practice, evidence-based care, health care financing, and a patient-centered approach to care delivery. The recent dust-up over the release of surgeon-specific outcome data touches almost all of them.
ProPublica, a not-for-profit organization devoted to investigative “journalism in the public interest” got the ball rolling last week with the publication of their “surgeon scorecard.” They compiled 5 years of Medicare data (2009-2013) on 8 generally elective surgical procedures: Knee and hip replacement, laparoscopic cholecystectomy, lumbar spinal fusion (broken out by anterior and posterior approach), “complete” prostatectomy, TURP and cervical spinal fusion. For each one, they identified a list of principal diagnosis codes associated with a hospital re-admission within 30 days of the surgery that could reasonably be interpreted as complications of the index surgery. For example, if a patient had undergone knee replacement and was admitted within 30 days with a principal diagnosis of “infection due to prosthesis” then that “counted” as a complication of surgery. Details of the methodology were provided online. The complication rates were adjusted by patient age, gender, and a few other variables, and their user-friendly tool allows for easy look-up of complication rates by surgeon or hospital.
Continue reading Good Enough?
A few recent experiences have me thinking about death.
The first was hearing a story on the radio about how physicians “manage” their deaths. The gist of it was that physicians are more likely to die at home without aggressive life-extending interventions than the general public. The implication was that more people would have a “better” death, more in accord with their own wishes, if frank discussions about end of life care were more common.
I didn’t think too much about the story, which registered only a “no kidding” in my mind when I heard it, until I thought about it in the context of two deaths that touched me this past week.
Continue reading Talking About Death
What does someone having a heart attack look like? I think the New York Times captured what many of us probably have in mind, when they published this picture as part of a recent series on advances in cardiovascular care:
Mark Makela for The New York Times. Retrieved from http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html
Here is the iconic middle-aged guy, in extremis, pointing to his chest, with a team of health care professionals at the bedside. There are also signs of initial management – he has ECG electrodes on his chest, an IV in his left arm, what looks like monitor/defibrillator pads on his right chest and below his left arm and, of course, an oxygen mask.
What is wrong with this picture?
Continue reading Rethinking a No-Brainer
A recent FDA advisory panel recommended the approval of 2 new agents in a novel class of cholesterol lowering drugs known as PCSK-9 inhibitors. What makes this remarkable is that these drugs illustrate all the promise and pitfalls of modern pharmaceutical development.
First, a little science. The target of the new drugs – a protein named proprotein convertase subtilisin/kexin type 9 (PCSK-9) – was discovered in 2001. Two years later, investigators reported that “gain-of-function” mutations in the gene that codes for PCSK-9 were associated with familial hypercholesterolemia and high rates of atherosclerotic vascular disease. Mutations of the gene that led to reductions in the function of PCSK-9 were associated with low LDL-cholesterol levels, and a lower incidence of vascular disease. That made the compelling case that PCSK-9 had a counter-regulatory function in LDL-cholesterol metabolism, so that interfering with its function would lead to lower cholesterol levels.
Continue reading The New Paradigm
I have written previously about the potential impact of mobile apps and ubiquitous computing on health and healthcare delivery, but I admit I did not see this one coming. The current issue of The New England Journal of Medicine has a report from a research group in Sweden that developed a system – and tested it in a randomized controlled trial – to use smartphones to alert CPR-trained bystanders when there was a nearby cardiac arrest. This figure from the paper describes how it works:
Continue reading Crowdsourcing CPR
I have written previously about some “aha moments” that I have had as a clinician, when something that I knew was coming seemed to arrive with a thud in my own practice. I had another one of those moments a couple of weeks ago.
I was finishing up with a new patient, and had explained to him and his wife my assessment and recommendations, and had answered a bunch of questions they had. I was frankly feeling pretty good about how the encounter had gone and as he was walking out of the exam room he said (more or less): “thanks doc; I’m glad I came to see you, and I am going to give you a really nice review on Yelp.” He was not kidding.
I didn’t know quite what to say immediately, but I ended up thanking him (somewhat awkwardly, I suspect) and then recovered enough to tell him that while I would – of course – appreciate a nice review on Yelp, I wanted him to know that he might be getting a patient satisfaction survey in the mail, and I would really appreciate it if he filled it out and sent it back in. Encounter over. New world order in place.
Continue reading Yelp!
Last year I pointed out that Memorial Day was slipping in our collective consciousness from a day of solemn remembrance of those who died in the service of our country to just another “vacation Monday” or the marker of the start of the Summer season.
A recent experience reinforced for me just how important it is for us to make sure we never lose the deeper meaning of the day.
My wife and I traveled to Washington, DC a couple of weeks ago to witness the “arsenal of democracy” flyover. The event included over 50 WWII warplanes, and coincided with the 70th anniversary of “V-E (Victory in Europe) Day” – the defeat of Germany by Allied Forces. As an airplane buff, I found the flyover stirring. It was an historic opportunity to see the “warbirds” aloft, flying in formation, instead of on the pages of history books or on static display in a museum.
Continue reading Memorial Day
Every so often the Journal of the American Medical Association (JAMA) is devoted to a single topic. The May 12 edition was devoted to “professionalism and governance” and the articles addressed a range of related subjects from medical education to board certification. I was particularly drawn, for obvious reasons, to the section on “professionalism and employment.”
I think it is fair to say that physicians have often cited their commitment to professionalism as a justification for the high value placed on independent private practice. That is, independence – of insurance companies, corporate overlords or pretty much anybody telling them how to practice – is the only way to assure that they can consistently act in the best interests of their patients.
This way of thinking is now severely challenged.
Continue reading Professionalism
I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).
Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.
Fast forward to now.
Continue reading Congress and Dr. Bayes
Some time ago, I wrote that the maintenance of certification requirements of the American Board of Internal Medicine (ABIM) were more like a shakedown than a civic-minded attempt to improve the quality of medical care. I was not alone. Many professional societies, including, I am happy to say, the American College of Cardiology were highly critical of the program.
The good news is that the ABIM heard the critics loud and clear. Despite earlier public defense of the policies, it has since done a complete “about face” and is now in a “listening” mode in anticipation of revising the program.
Continue reading I Guess They Were Listening