Category Archives: healthcare

data saving lives, healthcare

To Make Hospitals Less Deadly, a Dose of Data

The true horror of modern hospital medicine is starting to be revealed.

440,000 deaths per year (up from 96,000 based on 1984 data) – one sixth of all deaths nationally, making preventable hospital error the third leading cause of death in the United States.

http://opinionator.blogs.nytimes.com/2013/12/04/to-make-hospitals-less-deadly-a-dose-of-data/?hp&rref=opinion&_r=1

To Make Hospitals Less Deadly, a Dose of Data

DECEMBER 4, 2013, 11:00 AM
By TINA ROSENBERG

Going to the hospital is supposed to be good for you. But in an alarming number of cases, it isn’t. And often it’s fatal. In fact it is the most dangerous thing most people will do.

Until very recently, health care experts believed that preventable hospital error caused some 98,000 deaths a year in the United States — a figure based on 1984 data. But a new report from the Journal of Patient Safety using updated data holds such error responsible for many more deaths — probably around some 440,000 per year. That’s one-sixth of all deaths nationally, making preventable hospital error the third leading cause of death in the United States. And 10 to 20 times that many people suffer nonlethal but serious harm as a result of hospital mistakes.

Most of us decide which hospital to go to (that is, when we get to decide) with zero data about hospital safety. Information, however, is gradually reaching the public, and it can do more than just help us choose wisely. When patients can judge hospitals on their safety records, hospitals will become safer. Just as publishing health care prices will drive them down, publishing safety information will drive hospital safety up.

In theory, finding this information shouldn’t be a problem. Hospitals began to track errors seriously around 2000. The federal government’s Centers for Medicare and Medicaid Services began collecting information on hospital quality in 2003, and since 2005 has been posting information on the website Hospital Compare. Many states have their own websites.

Other organizations compile this information as well, such as Consumers Union’s Consumer Reports (subscription required), which scores hospitals on their safety and the quality of care. The Leapfrog Group, which represents employer purchasers of health care, scores hospitals on safety measures. (The hospital ranking site probably most familiar to readers, U.S. News’ Best Hospitals rankings, describes its mission as a very different one — to help patients with very difficult problems choose hospitals.)

All of these groups measure different things, which is why a hospital can rank near the top on one list and near the bottom on another. Most groups make money by charging hospitals to use their logo and ratings in their publicity. Consumer Reports is an exception — it doesn’t allow hospitals to advertise its rankings.

“There is no longer a question of whether or not people have a right to information about quality, and that hospitals should be transparent and accountable,” said Debra L. Ness, the president of the National Partnership for Women and Families. Ness is on the board of the National Quality Forum, the organization that sets standards for evaluating health care safety and quality. “It’s not so much any longer a debate about whether — it’s more about how.”

But so far, the answer to the question of how is “slowly.” There is a big advance coming — Hospital Compare plans to begin reporting on rates of MRSA (or methicillin-resistant Staphylococcus aureus, a drug-resistant bacteria) and C-diff (Clostridium difficile) infections this month. These are dangerous, high-prevalence infections — crucial safety issues to track. But they are an exception on Hospital Compare. Much of what the public wants to know isn’t there — and a lot of what’s there isn’t meaningful.

What’s your hospital’s rate of surgical site infection? You can find out if you live in California or Pennsylvania — states that collect exhaustive information on hospital infections and post it. The rest of us are out of luck. Hospital Compare will tell you only about colon surgery or abdominal hysterectomy — no knee replacement, heart bypass or any other surgery. How often does your local hospital leave a foreign object (like a surgical sponge) inside a patient? Or administer the wrong type of blood? Or allow a patient to develop a serious bed sore or a blood clot? Hospital Compare is now listing only old data for these errors, and has stopped updating those measures on the site.

What about the hospital’s record at preventing re-admission in the 30 days after discharge? We can find that out for Medicare patients (the data comes from Medicare claims), but not for the rest of us. “Hospital Compare has a lot of bells and whistles but underneath it is nothing,” said Leah Binder, the chief executive of The Leapfrog Group. “Most hospitals are rated as average on every measure, and most measures are not things of great interest. We’re further along, but we’re really in the dark ages on reporting information in a way the public can use.”

Measuring hospital safety is hard. Comparison, of course, requires everyone to be using the same measures — so how to reconcile the many variations hospitals use? And how do we know a measurement actually tells us what we think it does?

It’s easiest to measure how often hospitals carry out processes that are recognized to be best practice, such as whether the patient got treatment to prevent blood clots after certain types of surgery, or whether the patient’s temperature was kept steady in the operating room. Hospitals track such processes for their own internal quality controls.

This kind of process information dominates Hospital Compare and some of the independent rating organizations. (U.S. News’ rankings lean heavily on a hospital’s reputation, which earns it heavy criticism.)

But tracking processes doesn’t produce the kind of information patients need. Hospitals are doing so well on these measures they are topping out, offering no way to compare them. Some of the measures are only loosely related to patient outcomes. For example, Hospital Compare shows that the national average for the practice of discontinuing prophylactic antibiotics within 24 hours after surgery is 97 percent. Top marks — but there is little evidence showing that this practice is linked to fewer surgical site infections. And it’s outcomes that count.

Why doesn’t Hospital Compare list more outcomes? Hospitals argue — and they are right — that it is much more expensive and technically difficult to develop outcome measures than process measures. “We need measures that have scientific reliability and validity,” said Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy. “Hospitals need the engagement of medical staff. If medical staff doesn’t find the data credible then you lose them — they won’t be there in the quality improvement. “

But at times it seems as if hospitals aren’t trying very hard. They like to report process measures on which they score well. But with 440,000 deaths from hospital error per year, their record is poor on key safety outcomes. This somewhat dampens their enthusiasm for public reporting. And what hospitals want matters a lot. “At the end of the day, the providers have to implement this,” said Ness. “There has to be a reasonable amount of buy-in for it to work well.”

“If you just looked at Hospital Compare’s process measures, you’d assume that all hospitals in this country are doing extremely well,” said Binder. “This is misleading to the public because of the politics behind the scene of the website. Lobbyists for providers have been very effective at making sure what gets reported doesn’t have much teeth.”

Hospital Compare chooses what to display mainly using guidelines set by the National Quality Forum, which was established in 1999 in response to a government commission on consumer protection in health care. At the Quality Forum, groups representing health care consumers — patients and the corporations who pay for health care — are represented on all committees, and they hold a guaranteed majority on the most important committee. But patients can’t match the clout of the providers. “Hospitals are ever-present in this work,” said Lisa McGiffert, who is director of the Safe Patient Project at the Consumers Union and has been a consumer representative on several Quality Forum committees. “They have lobbyists all over Congress and administration folks. They outnumbered us on the committees that I have been on at N.Q.F. When I was on the infections committee I was rolled over constantly.”

In a December 2011 meeting, the Measurement Application Partnership, a committee run by the Quality Forum, voted — over the objection of consumer and purchaser representatives — not to endorse reporting on several different serious hospital errors that were already on Hospital Compare. Hospital Compare then stopped updating data on air embolism, sponges or instruments left in a patient, serious bed sores and blood clots, among other events.

No one thought the raw data was unfair to hospitals — the data probably undercounted the number of hospital errors, said Foster. But hospitals argued that in some cases, the per-hospital numbers were so small the differences between hospitals might have been random, a conclusion supported by an independent review. (Hospitals have fought changes that would make reporting more complete — so it takes chutzpah to argue that the numbers are too small to publish.) “We agree with the concept,” Foster said. “But the way the measures are executed makes them very unreliable and, we believe, invalid. You don’t know that what you are looking at is an accurate representation of a hospital’s performance.”

Advocates for health care consumers argued that it didn’t matter — just knowing the number of errors was important. “Do you as an American have the right to know if the hospital down the street left an object in a patient?” said Binder. “That information has now been taken out of the hands of the consumer by lobbyists. We should always tilt towards transparency.”

Poor or irrelevant data keeps patients from finding the information they need. Another problem is that the data that’s there isn’t presented in a way people can easily use.

Hospital Compare cuts very thick slices. There’s below average, above average and average, which is the score of the vast majority of hospitals. And most patients simply don’t know about Hospital Compare. That’s not the government’s fault, but it does illustrate the need for translator organizations such as Consumer Reports — which has five categories, not three — and Leapfrog, which issues letter grades, with more detail available for those who want it.

Leapfrog’s twice-yearly data release gets a lot of coverage. McGiffert said that when Consumer Reports first came out with ratings for central-line and surgical site infections, some hospitals protested that the data was wrong. But it was the same data hospitals had submitted for state reports. “We were using data that had already been on state websites, but nobody had paid attention to it,” she said. “Agencies are never going to do a media push when they publish these.”

That media push reaches more patients, and it forces hospitals to focus on safety. “These are a major factor in getting hospitals’ attention,” said McGiffert. She said that hospitals in states that required public reporting were far more likely to adopt quality-improvement practices.

Binder said that except for advances in doctors’ using computers to enter treatment orders, hospital safety records, as a group, are not improving. This is hardly surprising. What gets measured gets done, and many aspects of safety are still not even measured. The Journal of Patient Safety study found 210,000 “detectable” deaths per year — the number they eventually fixed on of 440,000 reflected the estimate that half or two-thirds of all such deaths are never counted. “That’s a big range,” said Binder. “It sounds so high, but what more frightening is that we still don’t know. Nobody’s counting the bodies.”

Join Fixes on Facebook and follow updates on twitter.com/nytimesfixes. To receive e-mail alerts for Fixes columns, sign up here.

Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”

By TINA ROSENBERG

Going to the hospital is supposed to be good for you. But in an alarming number of cases, it isn’t. And often it’s fatal. In fact it is the most dangerous thing most people will do.

Until very recently, health care experts believed that preventable hospital error caused some 98,000 deaths a year in the United States — a figure based on 1984 data. But a new report from the Journal of Patient Safety using updated data holds such error responsible for many more deaths — probably around some 440,000 per year. That’s one-sixth of all deaths nationally, making preventable hospital error the third leading cause of death in the United States. And 10 to 20 times that many people suffer nonlethal but serious harm as a result of hospital mistakes.

Most of us decide which hospital to go to (that is, when we get to decide) with zero data about hospital safety. Information, however, is gradually reaching the public, and it can do more than just help us choose wisely. When patients can judge hospitals on their safety records, hospitals will become safer. Just as publishing health care prices will drive them down, publishing safety information will drive hospital safety up.

In theory, finding this information shouldn’t be a problem. Hospitals began to track errors seriously around 2000. The federal government’s Centers for Medicare and Medicaid Services began collecting information on hospital quality in 2003, and since 2005 has been posting information on the website Hospital Compare. Many states have their own websites.

Other organizations compile this information as well, such as Consumers Union’s Consumer Reports (subscription required), which scores hospitals on their safety and the quality of care. The Leapfrog Group, which represents employer purchasers of health care, scores hospitals on safety measures. (The hospital ranking site probably most familiar to readers, U.S. News’ Best Hospitals rankings, describes its mission as a very different one — to help patients with very difficult problems choose hospitals.)

All of these groups measure different things, which is why a hospital can rank near the top on one list and near the bottom on another. Most groups make money by charging hospitals to use their logo and ratings in their publicity. Consumer Reports is an exception — it doesn’t allow hospitals to advertise its rankings.

“There is no longer a question of whether or not people have a right to information about quality, and that hospitals should be transparent and accountable,” said Debra L. Ness, the president of the National Partnership for Women and Families. Ness is on the board of the National Quality Forum, the organization that sets standards for evaluating health care safety and quality. “It’s not so much any longer a debate about whether — it’s more about how.”

But so far, the answer to the question of how is “slowly.” There is a big advance coming — Hospital Compare plans to begin reporting on rates of MRSA (or methicillin-resistant Staphylococcus aureus, a drug-resistant bacteria) and C-diff (Clostridium difficile) infections this month. These are dangerous, high-prevalence infections — crucial safety issues to track. But they are an exception on Hospital Compare. Much of what the public wants to know isn’t there — and a lot of what’s there isn’t meaningful.

What’s your hospital’s rate of surgical site infection? You can find out if you live in California or Pennsylvania — states that collect exhaustive information on hospital infections and post it. The rest of us are out of luck. Hospital Compare will tell you only about colon surgery or abdominal hysterectomy — no knee replacement, heart bypass or any other surgery. How often does your local hospital leave a foreign object (like a surgical sponge) inside a patient? Or administer the wrong type of blood? Or allow a patient to develop a serious bed sore or a blood clot? Hospital Compare is now listing only old data for these errors, and has stopped updating those measures on the site.

What about the hospital’s record at preventing re-admission in the 30 days after discharge? We can find that out for Medicare patients (the data comes from Medicare claims), but not for the rest of us. “Hospital Compare has a lot of bells and whistles but underneath it is nothing,” said Leah Binder, the chief executive of The Leapfrog Group. “Most hospitals are rated as average on every measure, and most measures are not things of great interest. We’re further along, but we’re really in the dark ages on reporting information in a way the public can use.”

Measuring hospital safety is hard. Comparison, of course, requires everyone to be using the same measures — so how to reconcile the many variations hospitals use? And how do we know a measurement actually tells us what we think it does?

It’s easiest to measure how often hospitals carry out processes that are recognized to be best practice, such as whether the patient got treatment to prevent blood clots after certain types of surgery, or whether the patient’s temperature was kept steady in the operating room. Hospitals track such processes for their own internal quality controls.

This kind of process information dominates Hospital Compare and some of the independent rating organizations. (U.S. News’ rankings lean heavily on a hospital’s reputation, which earns it heavy criticism.)

But tracking processes doesn’t produce the kind of information patients need. Hospitals are doing so well on these measures they are topping out, offering no way to compare them. Some of the measures are only loosely related to patient outcomes. For example, Hospital Compare shows that the national average for the practice of discontinuing prophylactic antibiotics within 24 hours after surgery is 97 percent. Top marks — but there is little evidence showing that this practice is linked to fewer surgical site infections. And it’s outcomes that count.

Why doesn’t Hospital Compare list more outcomes? Hospitals argue — and they are right — that it is much more expensive and technically difficult to develop outcome measures than process measures. “We need measures that have scientific reliability and validity,” said Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy. “Hospitals need the engagement of medical staff. If medical staff doesn’t find the data credible then you lose them — they won’t be there in the quality improvement. “

But at times it seems as if hospitals aren’t trying very hard. They like to report process measures on which they score well. But with 440,000 deaths from hospital error per year, their record is poor on key safety outcomes. This somewhat dampens their enthusiasm for public reporting. And what hospitals want matters a lot. “At the end of the day, the providers have to implement this,” said Ness. “There has to be a reasonable amount of buy-in for it to work well.”

“If you just looked at Hospital Compare’s process measures, you’d assume that all hospitals in this country are doing extremely well,” said Binder. “This is misleading to the public because of the politics behind the scene of the website. Lobbyists for providers have been very effective at making sure what gets reported doesn’t have much teeth.”

Hospital Compare chooses what to display mainly using guidelines set by the National Quality Forum, which was established in 1999 in response to a government commission on consumer protection in health care. At the Quality Forum, groups representing health care consumers — patients and the corporations who pay for health care — are represented on all committees, and they hold a guaranteed majority on the most important committee. But patients can’t match the clout of the providers. “Hospitals are ever-present in this work,” said Lisa McGiffert, who is director of the Safe Patient Project at the Consumers Union and has been a consumer representative on several Quality Forum committees. “They have lobbyists all over Congress and administration folks. They outnumbered us on the committees that I have been on at N.Q.F. When I was on the infections committee I was rolled over constantly.”

In a December 2011 meeting, the Measurement Application Partnership, a committee run by the Quality Forum, voted — over the objection of consumer and purchaser representatives — not to endorse reporting on several different serious hospital errors that were already on Hospital Compare. Hospital Compare then stopped updating data on air embolism, sponges or instruments left in a patient, serious bed sores and blood clots, among other events.

No one thought the raw data was unfair to hospitals — the data probably undercounted the number of hospital errors, said Foster. But hospitals argued that in some cases, the per-hospital numbers were so small the differences between hospitals might have been random, a conclusion supported by an independent review. (Hospitals have fought changes that would make reporting more complete — so it takes chutzpah to argue that the numbers are too small to publish.) “We agree with the concept,” Foster said. “But the way the measures are executed makes them very unreliable and, we believe, invalid. You don’t know that what you are looking at is an accurate representation of a hospital’s performance.”

Advocates for health care consumers argued that it didn’t matter — just knowing the number of errors was important. “Do you as an American have the right to know if the hospital down the street left an object in a patient?” said Binder. “That information has now been taken out of the hands of the consumer by lobbyists. We should always tilt towards transparency.”

Poor or irrelevant data keeps patients from finding the information they need. Another problem is that the data that’s there isn’t presented in a way people can easily use.

Hospital Compare cuts very thick slices. There’s below average, above average and average, which is the score of the vast majority of hospitals. And most patients simply don’t know about Hospital Compare. That’s not the government’s fault, but it does illustrate the need for translator organizations such as Consumer Reports — which has five categories, not three — and Leapfrog, which issues letter grades, with more detail available for those who want it.

Leapfrog’s twice-yearly data release gets a lot of coverage. McGiffert said that when Consumer Reports first came out with ratings for central-line and surgical site infections, some hospitals protested that the data was wrong. But it was the same data hospitals had submitted for state reports. “We were using data that had already been on state websites, but nobody had paid attention to it,” she said. “Agencies are never going to do a media push when they publish these.”

That media push reaches more patients, and it forces hospitals to focus on safety. “These are a major factor in getting hospitals’ attention,” said McGiffert. She said that hospitals in states that required public reporting were far more likely to adopt quality-improvement practices.

Binder said that except for advances in doctors’ using computers to enter treatment orders, hospital safety records, as a group, are not improving. This is hardly surprising. What gets measured gets done, and many aspects of safety are still not even measured. The Journal of Patient Safety study found 210,000 “detectable” deaths per year — the number they eventually fixed on of 440,000 reflected the estimate that half or two-thirds of all such deaths are never counted. “That’s a big range,” said Binder. “It sounds so high, but what more frightening is that we still don’t know. Nobody’s counting the bodies.”

Join Fixes on Facebook and follow updates on twitter.com/nytimesfixes. To receive e-mail alerts for Fixes columns, sign up here.

Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”

complex adaptive systems, cool, data saving lives, healthcare, healthy habits, policy, politics, quantified self, rapid learning health systems, research methodology, technology

Hammerbacher, Sinai and Minerva…

Top piece on Sinai’s vision. Everything’s lined up there except the doctors – hmmm…. They’ll need some amazing insights to bust through the inertia, but expect they’ll glean them…

http://www.fastcoexist.com/3022050/futurist-forum/in-the-hospital-of-the-future-big-data-is-one-of-your-doctors

In The Hospital Of The Future, Big Data Is One Of Your Doctors

December 5, 2013 | 7:30 AM

From our genomes to Jawbones, the amount of data about health is exploding. Bringing on top Silicon Valley talent, one NYC hospital is preparing for a future where it can analyze and predict its patients’ health needs–and maybe change our understanding of disease.

The office of Jeff Hammerbacher at Mount Sinai’s Icahn School of Medicine sits in the middle of one of the most stark economic divides in the nation. To Hammerbacher’s south are New York City’s posh Upper East Side townhouses. To the north, the barrios of East Harlem.

What’s below is most interesting: Minerva, a humming supercomputer installed last year that’s named after the Roman goddess of wisdom and medicine.

It’s rare to find a supercomputer in a hospital, even a major research center and medical school like Mount Sinai. But it’s also rare to find people like Hammerbacher, a sort of human supercomputer who is best known for launching Facebook’s data science teamand, later, co-founding Cloudera, a top Silicon Valley “big data” software company where he is chief scientist today. After moving to New York this year to dive into a new role as a researcher at Sinai’s medical school, he is setting up a second powerful computing cluster based on Cloudera’s software (it’s called Demeter) and building tools to better store, process, mine, and build data models. “They generate a pretty good amount of data,” he says of the hospital’s existing electronic medical record system and its data warehouse that stored 300 million new “events” last year. “But I would say they are only scratching the surface.”

Could there actually be three types of Type 2 diabetes? A look at the health data of 30,000 volunteers hints that we know less than we realize. Credit: Li Li, Mount Sinai Icahn School of Medicine, and Ayasdi

Combined, the circumstances make for one of the most interesting experiments happening in hospitals right now–one that gives a peek into the future of health care in a world where the amount of data about our own health, from our genomes to ourJawbone tracking devices, is exploding.

“What we’re trying to build is a learning health care system,” says Joel Dudley, director of biomedical informatics for the medical school. “We first need to collect the data on a large population of people and connect that to outcomes.”

To imagine what the hospital of the future could look like at Mount Sinai, picture how companies like Netflix and Amazon and even Facebook work today. These companies gather data about their users, and then run that data through predictive models and recommendation systems they’ve developed–usually taking into account a person’s past history, maybe his or her history in other places on the web, and the history of “similar” users–to make a best guess about the future–to suggest what a person wants to buy or see, or what advertisement might entice them.

Through real-time data mining on a large scale–on massive computers like Minerva–hospitals could eventually operate in similar ways, both to improve health outcomes for individual patients who enter Mount Sinai’s doors as well as to make new discoveries about how to diagnose, treat, and prevent diseases at a broader, public health scale. “It’s almost like the Hadron Collider approach,” Dudley says. “Let’s throw in everything we think we know about biology and let’s just look at the raw measurements of how these things are moving within a large population. Eventually the data will tell us how biology is wired up.”

Dudley glances at his screen to show the very early inklings of this vision of what “big data” brought to the world of health care and medical research could mean.

On it (see the figure above) is a visualization of the health data of 30,000 Sinai patients who have volunteered to share their information with researchers. He points out, in color, three separate clusters of the people who have Type 2 diabetes. What we’re looking at could be an entirely new notion of a highly scrutinized disease. “Why this is interesting is we could really be looking at Type 2, Type 3, and Type 4 diabetes,” says Dudley. “Right now, we have very coarse definitions of disease which are not very data-driven.” (Patients on the map are grouped by how closely related their health data is, based on clinical readings like blood sugar and cholesterol.)

From this map and others like it, Dudley might be able to pinpoint genes that are unique to diabetes patients in the different clusters, giving new ways to understand how our genes and environments are linked to disease, symptoms, and treatments. In another configuration of the map, Dudley shows how racial and ethnic genetic differences may define different patterns of a disease like diabetes–and ultimately, require different treatments.

These are just a handful of small examples of what could be done with more data on patients in one location, combined with the power to process it. In the same way Facebook shows the social network, this data set is the clinical network. (The eventual goal is to enroll 100,000 patients in what’s called the BioMe platform to explore the possibilities in having access to massive amounts of data.) “There’s nothing like that right now–where we have a sort of predictive modeling engine that’s built into a health care system,” Dudley says. “Those methods exist. The technology exists, and why we’re not using that for health care right now is kind of crazy.”

While Sinai’s goal is to use these methods to bring about more personalized diagnoses and treatments for a wide variety of diseases, such as cancer or diabetes, and improve patient care in the hospital, there are basic challenges that need to be overcome in order to making this vision achievable.

Almost every web company was born swimming in easily harvested and mined data about users, but in health care, the struggle has for a long time been more simple: get health records digitized and keep them private, but make them available to individual doctors, insurers, billing departments, and patients when they need them. There’s not even a hospital’s version of a search engine for all its data yet, says Hammerbacher, and in the state the slow-moving world of health care is in today, making predictions that would prevent disease could be just the icing on the cake. “Simply centralizing the data and making it easily available to a broad base of researchers and clinicians will be a powerful tool for developing new models that help us understand and treat disease,” he says.

Sinai is starting to put some of these ideas into clinical practice at the hospital. For example, in a hint of more personalized medicine that could come one day, the FDA is beginning to issue labels for some medicines that dictate different doses for patients who have a specific genetic variant (or perhaps explain that they should avoid the medicine altogether). The “Clipmerge” software that the hospital is beginning to now use makes it easier for doctors to quickly search and be notified of these kinds of potential interactions on an electronic medical record form.

On the prediction side, the hospital has already implemented a predictive model called PACT into its electronic medical record system. It is used to predict the likelihood that a discharged patient will come back to the hospital within 90 days (the new health care law creates financial incentives for hospitals to reduce their 90-day readmission rate). Based on the prediction, a high-risk patient at the medical center now might actually receive different care, such as being assigned post-care coordinator.

Eventually, there will be new kinds of data that can be put in mineable formats and linked to electronic patient records, from patient satisfaction surveys and doctors’ clinical notes to imaging data from MRI scans, Dudley says.

Right now, for example, the growing volumes of data generated from people’s fitness and health trackers is interesting on the surface, but it’s hard to glean anything meaningful for individuals. But when the data from thousands of people are mined for signals and links to health outcomes, Dudley says, it’s likely to prove valuable in understanding new ways to prevent disease or detect it at the earliest signs.

A major limitation to this vision is the hospital’s access to all of these new kinds of data. There are strict federal laws that govern patient privacy, which can make doctors loathe to experiment with ways to gather it or unleash it. And there are many hoops today to transferring patient data from one hospital or doctor to another, let alone from all the fitness trackers floating around. If patients start demanding more control over their own health data and voluntarily provide it to doctors, as Dudley believes patients will start to do, privacy could become a concern in ways people don’t expect or foresee today–just as it has on the Internet.

One thing is clear: As the health care system comes under pressure to cut costs and implement more preventative care, these ideas will become more relevant. Says Dudley: “A lot of people do research on computers, but I think what we’re hoping for is that we’re going to build a health care system where complex models … are firing on an almost day-to-day basis. As patients are getting information about them put in the electronic medical record system there will be this engine in the background.”

 

JESSICA LEBER

data saving lives, healthcare, rapid learning health systems

Clinical analytics delivering results…

Two excellent factoids in support of clinical analytics:
1. Kaiser Permanente: “Today you have a 26% lower chance of dying in one of our hospitals than you do in other hospitals,” said Dr. Mattison, adding that Kaiser is starting to lower its mortality rate much faster than the national average. “A lot of this is directly rated to how we use data and integrate data,” he said.
2. University of Pittsburgh Medical Center has slashed readmission rates by 37% since it began using analytics to predict which patients were more likely to be readmitted to the hospital within 30 days.
The source WSJ posts are paywalled, but UPMC are using the Microsoft solution I was working on. Interestingly, it only requires administrative data to deliver its impact.
In discussions with WentWest Medicare Local, they have access to GP data and hospital data, which would start to fillout the picture in an amazing way…

Wednesday, December 11, 2013

There Is A Real Sting In The Tail In These Great Reported Results From The Use Of Analytics In Healthcare.

Two very interesting reports appeared a week or two ago.
December 5, 2013, 7:12 PM ET

Data Helps Drive Lower Mortality Rate at Kaiser

REDWOOD CITY, CALIF. — Kaiser Permanente’s use of data analytics is helping it lower hospital mortality rates and look for ways to diagnose illnesses earlier. John Mattison, chief medical information officer at Kaiser spoke, Thursday, at VentureBeat’s Data Science Summit in Silicon Valley. Dr. Mattison predicts that by the year 2020, ten times more medical research will be generated by analyzing vast quantities of medical data than by conventional models of clinical research.
Over the past several years, Kaiser Permanente’s hospitals in southern California – the region with the most members — have enjoyed a lower mortality rate than the national average, according to data from the Centers for Medicare and Medicaid Services. “Today you have a 26% lower chance of dying in one of our hospitals than you do in other hospitals,” said Dr. Mattison, adding that Kaiser is starting to lower its mortality rate much faster than the national average. “A lot of this is directly rated to how we use data and integrate data,” he said.
Kaiser Permanente has some advantages in data collection over other medical providers because it provides physician, hospital and pharmacy services as well as health insurance to patients. All of those records are electronic. When a patient visits a Kaiser hospital, their entire health record, including doctor visits and medications, is immediately available. Kaiser can easily track patient outcomes after hospital procedures because patients see their doctors within the Kaiser system for follow-up visits. It’s a closed loop and all of that information resides in one place.
The informatics department at Kaiser, which is growing, looks at medical studies as well as information from its anonymized pool of information about patient outcomes to make implementable recommendations that it sends to physicians and hospitals through information alerts. One of the most high profile examples of this happened about a decade ago when Kaiser looked at its database of 1.4 million members and discovered that patients who took Vioxx were more likely to suffer a heart attack or sudden cardiac death than those who took a competing medication. Physicians were resistant to these alerts in the early years but the culture has changed and the informatics department continues to get requests for more of these alerts, said Dr. Mattison.
More here:
We also had this appear on the very same day.
December 5, 2013, 10:32 AM ET

Analytics Helps UPMC Slash Readmission Rates

University of Pittsburgh Medical Center has slashed readmission rates by 37% since it began using analytics to predict which patients were more likely to be readmitted to the hospital within 30 days.
That represents considerable savings for the hospital in terms of providing urgent care, let alone saving the hospital from potential penalties levied by the Centers for Medicare and Medicaid Services for failing to lower those rates.
The trouble for most hospitals is that they’re geared up for the “average patient,” whereas no one is actually an average patient. The role of analytics at UPMC is to determine most precisely which course of treatment will be most effective for each individual.
“Analytics helps you determine who you should focus on,” said Dr. Pamela Peele, chief analytics officer for the UPMC Insurance Services Division during a visit to CIO Journal offices.
According to Dr. Peele, the factors that hospitals should pay attention to are “jaw-dropping.” Far from the actual health of the patient, those factors have to do with how patients used care in the past – what services they’ve received over time and whether the use of the services has been “lumpy or smooth” over time.
Lots more here:
What we have here are very positive reports of the value of analytics in improving hospital and health system performance at the level of the most important measure – improved clinical outcomes.
The sting in the tail is that both the organisations involved are very strategic users of Health IT and have been evolving and improving their Health IT infrastructures over decades. They also have integrated environments where EHR data from both hospitals and ambulatory systems is easily accessible as well as the billing / insurance information and all that can be used for analysis.
For Australian Hospitals they have no access to the GP records and Medicare Payment records – so it now becomes very tricky to obtain such benefits.
It is really only those organisations that hold relevant ambulatory, hospital and insurance information which is easily accessible, and that also have a very advanced IT infrastructure that can replicate this. I wonder are the gurus and NEHTA and DoH working out how these sorts of benefits can be replicated in Australia or is the plan to mine the PCEHR to do a very second best effort?
Time will tell I guess.
David.

 

 

complex adaptive systems, cool, data saving lives, entrepreneurship, file note, healthcare, healthy habits, meaning, musings, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology

Healthways…

http://www.healthways.com  || http://www.healthways.com.au

Christian Sellars from MSD put on a terrific dinner in Crows Nest, inviting a group of interesting people to come meet with his team, with no agenda:

  • Dr Paul Nicolarakis, former advisor to the Health Minister
  • Dr Linda Swan, CEO Healthways
  • Ian Corless, Business Development & Program Manager, Wentwest
  • Dr Kevin Cheng, Project Lead Diabetes Care Project
  • Dr Stephen Barnett, GP & University of Wollongong
  •  Warren Brooks, Customer Centricity Lead
  • Brendan Price, Pricing Manager
  • Wayne Sparks, I.T. Director
  • Greg Lyubomirsky, Director, New Commercial Initiatives
  • Christian Sellars, Director, Access 

MSD are doing interesting things in health. In Christian’s words, they are trying to uncouple their future from pills.

After some chair swapping, I managed to sit across from Linda Swan from Healthways. It was terrific. She’s a Stephen Leeder disciple, spent time at MSD, would have been an actuary if she didn’t do medicine, and has been on a search that sounds similar to mine.

Healthways do data-driven, full-body, full-community wellness.

They’re getting $100M multi-years contracts from PHIs.

Amazingly, they’ve incorporated social determinants of health into their framework.

And even more amazingly, they’ve been given Iowa to make healthier.

They terraform communities – the whole lot.

Linda believes their most powerful intervention is a 20min evidence-based phone questionnaire administered to patients on returning home, similar to what Shane Solomon was rolling out at the HKHA. But they also supplant junk food sponsorship of sport and lobby for improvements to footpaths etc.

Just terrific. We’re catching up for coffee in January.

data saving lives, healthcare, policy

RWJF Webinar recording – Transparency in healthcare price, cost and quality

This hour long webinar brings together presenters from a recent RWJF conference of the same name.
Of note:
> 24m 30s: demonstration of a new app (closed beta) “Hospital Adviser Medicare Hip & Knee” developed by Consumer Reports (US equivalent of Choice Magazine) using publicly released de-identified cost CMS government data (if only in AU!!) – tip: don’t get your hip or knee done in NYC
> presentation by Castlight Health – US analytics business providing employees and employers personalised price & quality transparency for procedures/conditions/doctors
> The conference found that transparency is necessary but not sufficient to deliver improvements in care.

> 49m 25s: Value-based pricing – the benefit of the care, not its cost

> 50m: providers don’t have feedback on their own performance (let alone payers and patients) – when providers see their own price competitiveness, they adjust their prices

> 56m: Leapfrong asked how can transparency be applied to over-utilization of procedures? By feedback to providers.

healthcare, musings, policy, politics

MJA Insight: Hard choices – Will Cairns

  • We cannot continue on our current course without depriving other societal domains that are essential to the long-term wellbeing of our community, such as education, physical infrastructure, aged care, environmental protection, the arts and recreation
  • When we eventually do act we will realise that there are a limited number of ways to constrain the proportion of community resources expended on health care.

    One is for funders to pay less for the things that are done.

    The second, and perhaps the simplest, is to not do things that are of little or no benefit. We could also ensure that, when there is a choice, the less expensive options are used. This is primarily a task for doctors but everyone is responsible.

    The third is to make sure that people do not have treatment that they do not want. This merely supports the right of people to make a choice not to start or persist with treatment that will not bring them sufficient benefit in terms of a quantity of a life of quality as they define it. This also requires community acceptance that individuals have the right to make such choices.

While thoughtful medical practice, systemic support of the right to individual choice and improved efficiency can buy us some time they are unlikely to be sufficient.

Perhaps the complex ecology of gridlocked self-interest means that struggling health systems must collapse and fail before they can be rebuilt, and we will just have to watch while it happens.

Surely a better outcome would be to work towards spending only what we can afford. These are not simple issues and the process might begin with an open discussion of our community values and the goals of health care. The sooner we start that discussion the better.

From: https://www.mja.com.au/insight/2013/47/will-cairns-hard-choices

complex adaptive systems, healthcare, healthy habits, nutrition, policy, politics, rapid learning health systems

BMJ: Can behavioural economics make us healthy

  • BE policies are by design less coercive and more effective than traditional approaches
  • It is generally far more effective to punish than to reward
  • Sticks masquerading as carrots – simultaneous, zero-sum incentives and penalties
  • References to policies which have and have not worked – but why can’t policy be research?
  • Conventional economics can therefore justify regulatory interventions, such as targeted taxes and subsidies, only in situations in which an individual’s actions imposes costs on others—for example, second hand cigarette smoke. But the potential reach of behavioural economics is much greater. By recognising the prevalence of less than perfectly rational behaviour, behavioural economics points to a large category of situations in which policy intervention might be justified—those characterised by costs which people impose on themselves (internalities), such as the long term health consequences of smoking on smokers.
  •  Is it fair to say that in a universal health care system, any preventable ill health imposes costs on others, as it is the tax payer who picks up the cost of treatment?
  • present bias: the tendancy for decision makers tend to put too much weight on costs and benefits that are immediate and too little on those that are delayed. Present bias can be used to positive effect by providing small, frequent (i.e. immediate) payments for beneficial behaviours e.g. smoking cessation, medication adherence, weight loss
  • “peanuts effect” decision error: the tendency to pay too little attention to the small but cumulative consequences of repeated decisions, such as the effect on weightof repeated consumption of sugared beverages or the cumulative health effect of smoking.
  • competition and peer support are more powerful forms of behaviourally mediated interventions

Care of Nicholas Gruen.

PDF: CanBehaviouralEconomicsMakeUsHealthier_BMJ

Similarly in Health Affairs: http://content.healthaffairs.org/content/32/4/661.short

healthcare, nutrition

New Yorker post; Weight loss drugs

  • not convinced this isn’t part of some pharma-sponsored PR campaign
  • reference to research indicating gastric bypass may be mediated via changes in flora more than changes in gastric physiology

Source: http://www.newyorker.com/online/blogs/elements/2013/12/diet-drugs-work-why-wont-doctors-prescribe-them.html

DECEMBER 4, 2013

DIET DRUGS WORK: WHY WON’T DOCTORS PRESCRIBE THEM?

POSTED BY 
 
obese-580.jpg

The woman sat on my exam table and pointed to her snug paper gown. “Doctor,” she said, “I need your help losing weight.”

I spent the next several minutes speaking with her about diet and exercise, the health risks of obesity, and the benefits of weight loss—a talk I’ve been having with my patients for more than twenty years. But, like the majority of Americans, most of my patients remain overweight.

Afterward, I realized that what my patient wanted was a pill that would make her lose weight. I could have prescribed her one of four drugs currently approved by the F.D.A.: two, phentermine and orlistat, that have been around for more than a decade, and two others, Belviq (lorcaserin) and Qsymia (a combination of phentermine and topiramate), that have recently come onto the market and are the first ever approved for long-term use. (Ian Parker wrote about the F.D.A.’s approval process for new medications in this week’s issue.) The drugs work by suppressing appetite, by increasing metabolism, and by other mechanisms that are not yet fully understood. These new drugs, along with beloranib—which produces more dramatic weight loss than anything currently available but is still undergoing clinical trials—were discussed with great excitement last month by experts and researchers at the international Obesity Week conference in Atlanta.

But I’ve never prescribed diet drugs, and few doctors in my primary-care practice have, either. Donna Ryan, an obesity specialist at the Pennington Biomedical Research Center at Louisiana State University, has found that only a small percentage of the doctors she has surveyed regularly prescribe any of the drugs currently approved by the F.D.A. Sales figures indicate that physicians haven’t embraced the new medications, Qsymia and Belviq, either.

The inauspicious history of diet drugs no doubt contributes to doctors’ reluctance to prescribe them. In the nineteen-forties, when doctors began prescribing amphetamines for weight loss,rates of addiction soared. Then, in the nineties, fen-phen, a popular combination of fenfluramine and phentermine, was pulled from the market when patients developed serious heart defects. Current medications are much safer, but they produce only modest weight loss, in the range of about five to ten per cent, and they do have side effects.

Still, as Ryan pointed out, doctors aren’t always shy about prescribing medications that cause side effects and yield undramatic results. A five to ten per cent weight loss might not thrill patients, or even nudge them out of being overweight or obese, but it can improve diabetes control, blood pressure, cholesterol, sleep apnea, and other complications of obesity. And, although the drugs aren’t covered by Medicare or most states’ Medicaid programs, private insurance coverage of weight-loss drugs has improved and is likely to expand further under theAffordable Care Act, which requires insurers to pay for obesity treatment. So what prevents physicians from prescribing these drugs?

Several leading experts and researchers attending Obesity Week told me that the problem is that, while specialists who study obesity view it as a chronic but treatable disease, primary-care physicians are not fully convinced that they should be treating obesity at all. Even thoughphysicians since Hippocrates have known that excess body fat can cause diseases, the American Medical Association announced that it would recognize obesity itself as a disease only a few months ago. These divergent views on obesity represent one of the widest gulfs of understanding between generalists and specialists in all of medicine.

Lee M. Kaplan, co-director of the Weight Center at Massachusetts General Hospital, thinks that some bias comes from the average physician’s lack of appreciation for the complex physiology of weight homeostasis. Humans have evolved to avoid starvation rather than obesity, and we defend our body mass through an elaborate system involving the brain, the gut, fat cells, and a network of hormones and neurotransmitters, only a fraction of which have been identified. Obesity, Kaplan said, which represents dysfunction of this system, is likely not one disease but dozens.

That one person’s obesity is not like another’s may explain why some people lose a lot of weight with surgery, or a particular diet or drug, and some don’t. Kaplan thinks that if more doctors understood this, they’d view obesity treatment more receptively and realistically. He said, “If I were to say to you, ‘I have this drug that treats cancer,’ and you asked me, ‘What kind of cancer?,’ and I said, ‘All cancers,’ you’d laugh, because you recognize intuitively that cancer is a heterogeneous group of disorders. We’re going to look back on obesity one day and say the same thing.”

Obesity is potentially, in part, a neurological disease. Jeffrey Flier, an endocrinologist and dean of Harvard Medical School, has shown, like others, that repeatedly eating more calories than you burn can damage the hypothalamus, an area of the brain involved in eating and satiety. In other words, Big Gulps, Cinnabons, and Whoppers have altered our brains such that many people—particularly those with a genetic predisposition to obesity—find fattening foods all but impossible to resist once they’ve eaten enough of them. Louis J. Aronne, director of the Comprehensive Weight Control Program at New York-Presbyterian/Weill Cornell Medical Center, explained to me, “With so much calorie-dense food available, the hypothalamic neurons get overloaded and the brain can’t tell how much body fat is already stored. The response is to try to store more fat. So there’s very strong scientific evidence that obesity is not about people lacking willpower.”

But this message has not found its way into society, where obese people are still often considered self-indulgent and lazy, and face widespread discrimination. Several obesity experts told me they’ve encountered doctors who confide that they just didn’t like fat people and don’t enjoy taking care of them. Even doctors who treat obese patients feel stigmatized: “diet doctor” is not a flattering term. Donna Ryan, who switched from oncology to obesity medicine many years ago, recalls her colleagues’ surprise. “I had respect,” she says. “I was treating leukemia!”

George Bray, also of the Pennington Biomedical Research Center, thinks that socioeconomic factors play into physicians’ lack of enthusiasm for treating obesity. Bray points to the work ofAdam Drewnowski at the University of Washington, who has shown that obesity is, disproportionately, a disease of poverty. Because of this association, many erroneously see obesity as more of a social condition than a medical one, a condition that simply requires people to try harder. Bray said, “If you believe that obesity would be cured if people just pushed themselves away from the table, then why do you want to prescribe drugs for this non-disease, this ‘moral issue’? I think that belief permeates a lot of the medical field.”

Obesity experts with whom I spoke tended to be more optimistic than other physicians about the possibility that obesity can be treated successfully and that the obesity epidemic will be curbed. They point to exciting new research—for example, the finding that an alteration in gut bacteria, rather than mechanical shrinking of the stomach or intestine, may be what causes weight loss after gastric bypass. This raises the possibility that the benefits of surgery might become available without the surgery itself. They also note that public-health efforts seem to be reducing childhood obesity, even in poor communities. But they remain concerned that despite such promising developments, many physicians still don’t see obesity the way they do: as a serious, often preventable disease that requires intensive and lifelong treatment with a combination of diet, exercise, behavioral modification, surgery, and, potentially, drugs.

Louis Aronne thinks this will change as more physicians enter the field of obesity medicine, the physiology of obesity is better understood, and more effective treatment options become available. He likens the current attitude toward obesity to the prevailing attitude toward mental illness years ago. Aronne remembers, during his medical training, seeing psychotic patients warehoused and sedated, treated as less than human. He predicts that, one day, “some doctors are going to look back at severely obese patients and say, ‘What the hell was I thinking when I didn’t do anything to help them? How wrong could I have been?’ ”

Patients like the woman who asked me to help her lose weight may not have to wait that long. Specialists are now developing programs to aid primary-care physicians in treating obesity more aggressively and effectively. But we’ll have to want to treat it: as Kaplan argues, “Whether you call it a disease or not is not so germane. The root problem is that whatever you call it, nobody’s taking it seriously enough.”

Suzanne Koven is a primary-care doctor at Massachusetts General Hospital in Boston and writes the column “In Practice” at the Boston Globe.

Photograph by Patrick Allard/REA/Redux.

healthcare, healthy habits, nutrition, policy, politics, rapid learning health systems

Economist Intelligence Unit – Rethinking Cardiovascular Disease Prevention

 

Source: http://www.economistinsights.com/healthcare/opinion/heart-darkness%E2%80%94fighting-cvd-all-mind

CVD prevention at population level, such as a “fat tax” or smoking ban, relies heavily on regulation. This is its greatest strength – it can compel healthy behaviour (or seat belt wearing) – but also its greatest potential weakness. It inevitably involves some degree of coercion, which runs the risk of paternalism.It need not involve regulation, however. The same human flaws that are exploited by the food industry to persuade us to buy certain items at the check-out can also be used to persuade us to act in the interests of our own health. The current UK government is attempting to turn psychological weakness into an advantage outside of the legislative framework.

Its Behavioural Insights Team, commonly referred to as the “nudge unit”, is designed to seek “intelligent ways” to support and enable people to make better choices, using insights from behavioural science and medicine instead of increased rulemaking. Many of these goals overlap with CVD prevention, from smoking cessation to encouraging kids to eat healthier foods and walk to school more often. Early successes have brought them to the attention of the Obama administration in the US.

Besides the difficulties of making positive lifestyle changes, non-adherence to treatment is another significant obstacle to effective CVD prevention. Even after suffering a CVD incident, some patients forget to take their medication; other patients opt not to complete a course of treatment for other reasons, ranging from concerns about costs, the inconvenience involved with travel, to feelings of despondency caused by depression and anxiety. At its most anodyne, individuals frequently stop taking drugs prescribed for prevention after they feel better and think themselves cured.

This is part of a much wider medical problem: in the rich world adherence to treatment for all diseases is around 50%. Recognising the commercial opportunities here, private enterprise is looking to play a greater role. Earlier this year a US company called WellDoc launched a smartphone product aimed at giving type 2 diabetics better management of their treatment, through tailoured advice and motivational coaching. In the UK, meanwhile, a start-up calledImpact Health is developing a similar health psychology smartphone product to increase adherence to treatment among sufferers of Crohn’s disease.

CVD patients stand to benefit from such development in medical technology, although they may have to wait a little while yet. Impact Health’s online platform requires patients to have a smartphone. For this reason the start-up is targeting Crohn’s first and not CVD. As David Knull, one of its directors, explains, the profile of the average sufferer is generally around 30 years old—far younger than the average CVD patient, and much more likely to have a smartphone.

Report source: http://www.economistinsights.com/healthcare/analysis/heart-matter

Report PDF: The heart of the matter – Rethinking prevention of cardiovascular disease

The heart of the matter: Rethinking prevention of cardiovascular disease is an Economist Intelligence Unit report, sponsored by AstraZeneca. It investigates the health challenges posed by cardiovascular disease (CVD) in the developed and the developing world, and examines the need for a fresh look at prevention.

The report is also available to download in German, French, Italian, Spanish, Portuguese (Brazilian) and Mandarin—see the Multimedia tab

Why read this report

  • Cardiovascular disease (CVD) is the world’s leading killer. It accounted for 30% of deaths around the globe in 2010 at an estimated total economic cost of over US$850bn
  • The common feature of the disease across the world is its disproportionate impact on individuals from lower socio-economic groups
  • Prevention could greatly reduce the spread of CVD: reduced smoking rates, improved diets and other primary prevention efforts are responsible for at least half of the reduction in CVD in developed countries in recent decades…
  • …but prevention is little used. Governments devote only a small proportion of health spending to prevention of diseases of any kind—typically 3% in developed countries
  • Population-wide measures like smoking bans and “fat taxes” yield significant results but require political adeptness to succeed. There is no shortcut for the slow work of changing hearts and minds
  • The size of the CVD epidemic is such that a doctor-centred health system will not be able to cope. Innovative ways for nurses and non-medical personnel to provide preventative services are needed
  • A growing number of stakeholders are involved in CVD prevention, sharing the burden with governments. Now, greater collaboration across different sectors and interest groups should be encouraged
  • Collaboration works when incentives of stakeholders are aligned, including business. Finland’s famed North Karelia project suggests better alignment of interests is crucial to a successful “multi-sectoral” approach

Cardiovascular disease is the dominant epidemic of the 21st century. Dr Srinath Reddy, president of the World Heart Federation

We know a lot about what needs to be done, it just doesn’t get done. Beatriz Champagne, executive director of the InterAmerican Heart Foundation

Action at the country level will decide the future of the cardiovascular epidemic. Dr Shanthi Mendis, director ad interim, management of non-communicable diseases, WHO