A painful prick of the fingertip reveals a mountain of medical information for many diabetes patients. But health professionals have long struggled to find a reliable and painless way to gather blood sugar measurements. Just last year, Google announced that it was developing contact lenses that measure glucose levels in its user’s tears. But now, nanoengineers may have found an even easier way for diabetes patients to monitor their vital levels: temporary tattoos.
Amay Bandodkar, a researcher at the University of California, San Diego, has created a flexible sensor that uses a mild electrical current to measure glucose levels in a person’s body. Measuring blood sugar levels multiple times a day is vital for diabetes patients because it shows how well their body is managing their disease as well as the dose of insulin they require, if they need any at all. But because many people find needles unpleasant, they tend to avoid measuring their levels, which puts them at risk of developing serious medical complications. The new device is painless—It contains electrodes printed on a thin tattoo paper that patients can even dispose after use. “Presently the tattoo sensor can easily survive for a day,” Bandodkar said in a statement. “These are extremely inexpensive—a few cents—and hence can be replaced without much financial burden on the patient.”
The tattoo has already provided accurate glucose measures for seven healthy patients, the team reported in a recent issue of the journal Analytical Chemistry.The patients, all non-diabetics between the ages of 20 and 40, wore the tattoos before eating a sandwich and drinking a soda. Following the carb-rich meal, the tattoo recorded the spike in each patient’s glucose levels as accurately as a traditional finger-stick device. The tattoo is a few steps away from providing the numeric value of glucose levels, so scientists have to remove and analyze it in order to retrieve its measurements. Eventually, Bandodkar said the tattoo will have “Bluetooth capabilities to send this information directly to the patient’s doctor in real-time or store data in the cloud.”
The researchers hope the tattoo will eventually be used to monitor levels of other compounds in the blood, like metabolites, medications, or alcohol and illegal drugs. Whatever the application, the fewer needles the better.
A pinch of prevention will prevent a pound of turnstile medicine
PUBLISHED: 12 HOURS 58 MINUTES AGO | UPDATE: 12 HOURS 38 MINUTES AGO
A lack of infrastructure in Australia to care for more people in a community, rather than a hospital, costs us dearly. Photo: Louie Douvis
JOHN DWYER
Poorly considered and obviously unacceptable policies have forced the government to go back to the drawing board to consider ways to improve the cost effectiveness and sustainability of our health care system. This time let’s move beyond the government’s focus on having us pay more for a visit to our GP to concentrate on the evidence-based structural reforms we should be discussing. This time broad consultations are promised. Hopefully, the following facts and suggestions will influence decisions.
A good start would see the government stop talking about the fiscal sustainability of Medicare. Were it not for the destructive division of health care responsibilities shouldered by State and Federal governments, Canberra would not be looking at Medicare as if were isolated from the rest of the health care system. Hospital expenditure, at nearly $60 billion a year, dwarfs Medicare spending ($19 billion a year) and is increasing more rapidly. The immediate catalyst for changes to Medicare is not a fiscal crisis – our 9.3 per cent of GDP spent on health is about average for the OECD –but rather the unsatisfactory health outcomes delivered that are fuelling the growth in hospital care. A lack of any real infrastructure to provide our community with an improved capacity to prevent illness and care for more people in a community rather than hospital setting is costing us dearly.
More than 600,000 admissions to hospital each year (average cost more than $5000 per episode) could be avoided by a timely community intervention in the three weeks prior to admission. There is no doubt that the future of cost-effective, readily available hospital care is dependent on a reduction in the demand for hospital services. That must be the goal of a restructured Primary Care system. Last year Australians forked out $29 billion to supplement their health care (second only to the US in terms of out of pocket expenses). Much of this was spent on paying for surgery in the private sector. Public hospitals are swamped with complex medical patients seriously reducing their capacity to offer timely surgical services. Reducing medical admissions and restoring timely surgical services is a key to reigning in surgical costs and better educating the next generation of surgeons.
This time could our new health minister and her department open their eyes to international trends in cost effective health care that are producing better health outcomes. There is now an abundance of evidence that a focus on prevention in a personalised health system improves outcomes while slashing costs. Some systems have reduced hospital admissions by 42 per cent over the last decade. The British government has just been presented with a review that concluded that an extra 72 million ($132 million) spent on improving primary care in the community would save the system 1.9 billion ($3.5 billion) by 2020. The data available provides the government with a clear message that it does not want to hear. Only by spending more money on arestructuredMedicare will significant system wide savings be achievable.
A competent government would be looking at a timetable for introducing the highly successful Medical Home model of Primary Care, where teams of health professionals populate a practice and are available to enrolled patients. The infrastructure is available to help people avoid illness, have potential problems recognised earlier, offer co-ordinated in house care for people with chronic problems and care for many in the community currently sent to hospital. International experience tells us that a decade is required for the completion of necessary changes. We need to start on that journey and, fortunately, can do so without any panic about current health expenditure.
There is another related imperative that needs urgent action. Only 13 per cent of young doctors express any interest in becoming a GP. Only 1 per cent are contemplating a career as a rural GP. Primary Care training is rigorous and GPs are true specialists. How does all the rhetoric from Canberra about the pivotal role they play sit with the proposed $31 fee for a standard consultation. The discrepancy in the income potential for GPs when compared to that of other specialists is now huge.
Young doctors looking at the professional life of our GPs are uncomfortable with the current “fee for service” model that encourages turnstile medicine that is so professionally unfulfilling. Many GPs join corporate Primary Care providers preferring a salary. In New Zealand the government has facilitated 85 per cent of the nation’s GPs moving away from fee for service payments. The same is true for 65 per cent of US Primary Care physicians. Throughout the OECD health systems recognising the perverse incentives associated with fee for service remuneration are exploring changes that increase a GP’s remuneration for keeping people well.
There are numerous cost impositions in our health system that should be addressed before we are asked to pay more. Nine departments of health for 23 million people. A $5 billion dollar cost for the private health insurance rebate that could be better spent on achieving the above goals. $20 billion dollars spent on poor value or unnecessary procedures. The government asks: “if you don’t like our ideas then what would you do?” Well, here come the suggestions, please listen.
John Dwyer isEmeritus Professor of Medicine at the University of NSW.
“Data is just a shadow of human experience. We still need to connect the dots,” Smart Patients founder and Rock Health entrepreneur Roni Zeiger argued last week. Luckily, healthcare may finally be ready for big data—just so long as the algorithms don’t ruin your life.
Ten per cent of all health expenditure — as much as $15 billion a year — could be saved through a concerted effort to reduce wasteful programs, marginal treatments and avoidable errors, senior officials in the Department of Health have revealed. The department’s Strategic Policy Group was examining large-scale savings — including an evidence-based campaign of “disinvestment” in low-value programs, drugs and therapies — long before the Abbott government committed to its unpopular GP co-payment.
Documents obtained by The Australian under Freedom of Information laws show the group of deputy secretaries and other officials wanted to reduce spending on low-value interventions and get serious about combating avoidable side-effects, mistakes and infections.
“Members expressed strong interest in holding further discussions on the impact of waste and adverse events,’’ minutes from a November 2013 meeting state. “The discussions could be informed by work already under way in the department on disinvestment and by ongoing work by the Australian Commission for Safety and Quality in Health Care.”
Out of the public eye, the group — which reports directly to the secretary of the department — established an Optimising Value in Health Investment Working Group and talked with Treasury officials. The bureaucrats were keen to redirect money away from areas where there was minimal benefit and potential harm. The FOI documents shed new light on the workings of government and go some way to dispelling the myth that health bureaucrats have not recognised the need to pursue efficiencies and efficacy.
A department spokeswoman yesterday confirmed the work was ongoing. The Grattan Institute has called for more work to be done on the cost of hospital admissions and procedures, noting the cost of a hip replacement in NSW public hospitals varies by more than $16,000. It has estimated savings of $1bn a year from targeting such inefficiencies, as well as $500 million a year from workforce reform — making better use of highly skilled workers — and up to $500m a year through greater use of generic medicines. Some in government believe higher co-payments for drugs and services will make consumers spend less on unproven therapies and, with more of a financial stake in health, be more accepting of limits on access and subsidies.
There are questions about the cost of subsidising new and expensive drugs, especially those with few recipients and limited efficacy, with a Senate committee soon to report on the timing and affordability of access to cancer drugs.
The last federal budget committed to a controversial co-payment that has since been reworked. It also outlined plans to merge the safety and quality commission and five other agencies into a new Health Productivity and Performance Commission — a move that has already halted work on new performance reporting for emergency departments, elective surgery and infections — and replace Medicare Locals with a new primary care structure.
The budget did not take up the commission of audit’s recommendation for a broader, 12-month review of health policies and programs. The government has yet to finalise outstanding reviews into mental health, alcohol and drug services, after-hours GP services, super clinics and unproven natural therapies benefiting from the health insurance rebate. The government believed the health architecture established by Labor needed to be disassembled, price signals put in place for consumers, and growth opportunities given to the private sector before other savings could be pursued. Plans for a reworked $5 copayment — estimated to save $3.5bn by 2017-18 — will start to play out from Monday, when regulations setting new time frames for consultations come into effect.
The government wants GPs to focus on more serious cases, requiring longer consultations, but the Australian Medical Association has warned of $20 co-payments for shorter consultations. About 40,000 people have signed a petition against the copayment and new Health Minister Sussan Ley has yet to start the sales pitch, amid speculation the regulations could be disallowed by the Senate.
Rumors Swirl That Adam Bain Will Be The Next Twitter CEO, But Costolo’s Not Going Anywhere Yet
Since its founding in 2004, Palantir has managed to grow into a billion dollar company while being very surreptitious about what it does exactly. Conjecture abounds. The vague facts dredged up by reporters confirm that Palantir has created a data mining system used extensively by law enforcement agencies and security companies to connect the dots between known criminals.
TechCrunch has received a private document from 2013 which reveals the company’s extensive trove of data analysis tools and lists many of its key clients. The document is currently being passed around as an investor prospectus for a new secondary round.
In short, the description above is in part correct. But, thanks to this leaked information, we now know far more about the secretive company.
Palantir’s data analysis solution targets three industries: government, the finance sector and legal research. Each of these industries must wrestle with massive sets of data. To do this, Palantir’s toolsets are aimed at massive data caches, allowing litigators and the police to make connections otherwise invisible. For example, a firm hired by the Securities Investment Protection Corporation used Palantir’s software to sort through the mountains of data, over 40 years of records, to convict Ponzi schemer Bernie Madoff (of all things).
Palantir’s software sits on top of existing data sets and provides users with what seems like a revolutionary interface. Users do not have to use SQL queries or employ engineers to write strings in order to search petabytes of data. Instead, natural language is used to query data and results are returned in real-time.
Clients include the Los Angeles Police Department which used Palantir to parse and connect 160 data sets: Everyone from detectives to transit cops to homeland security officials uses Palantir at the LAPD. According to the document, Palantir provides a timeline of events and has helped the massive police department sort its records.
The leaked report quotes Sergeant Peter Jackson of the LAPD stating: “Detectives love the type of information it [Palantir] provides. They can now do things that we could not do before. They can now exactly see great information and the links between events and people. It’s brought great success to LAPD. It supports the cops on the streets and the officers doing the investigations. It is a great tool. They are becoming more efficient and more effective cops. Palantir is allowing them to better serve the public.”
Palantir explains that it is a toolset for use in human analysis on its website. However, we now understand that the service is a smarter way of displaying data for analysis by humans. It is capable of building comprehensive models of activity to detect suspicious anomalies and is even able to provide immunity to fraud thanks to strategies the founders learned while still at PayPal.
Palantir’s anti-fraud system uses algorithms to detect and isolate patterns designated by analysts. This approach was inspired by combating adaptive threats at PayPal, the leaked document states. Four out of the five people on the Palantir management team worked at PayPal. Palantir co-founder Peter Thiel was also a PayPal co-founder.
The document confirms that Palantir is employed by multiple US Government agencies. One of the company’s first contracts was with the Joint IED Defeat Organization in 2006. From 2007-2009 Palantir’s work in Washington expanded from eight pilots to more than 50 programs.
As of 2013, Palantir was used by at least 12 groups within the US Government including the CIA, DHS, NSA, FBI, the CDC, the Marine Corps, the Air Force, Special Operations Command, West Point, the Joint IED-defeat organization and Allies, the Recovery Accountability and Transparency Board and the National Center for Missing and Exploited Children. The Centers for Medicaid and Medicare Services were planning on pilot testing the use of Palantir in 2013 to investigate tips received through a hotline. A second test was run by the same organization to identify potentially fraudulent medical providers in the Southern region of the US.
However, as of 2013, not all parts of the military used Palantir. The U.S. Army developed its own data analysis tool called the Distributed Common Ground System at a cost of $2.3 billion, but it is believed that it is not very popular. The leaked document cites a 2012 study where 96% of the surveyed war fighters in Afghanistan recommended Palantir.
The prospectus holds that the US military used Palantir with great success. The Pentagon used the software to track patterns in roadside bomb deployment and was able to conclude that garage-door openers were being used as remote detonators. With Palantir, the Marines are now able to upload DNA samples from remote locations and tap into information gathered from years of collecting fingerprints and DNA evidence. The results are returned almost immediately. Without Palantir, the suspects would have already moved onto a different location by the time the field agents received the results.
Samuel Reading, a former Marine who works in Afghanistan for NEK Advanced Securities Group, a U.S. military contractor, was quoted in the document as saying It’s the combination of every analytical tool you could ever dream of. You will know every single bad guy in your area.”
“It’s the combination of every analytical tool you could ever dream of. You will know every single bad guy in your area.”
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The U.S. spy agencies also employed Palantir to connect databases across departments. Before this, most of the databases used by the CIA and FBI were siloed, forcing users to search each database individually. Now everything is linked together using Palantir. In fact, cyber analysts working for the now-defunct Information Warfare Monitor used the system to mine data on the China-based cyber groups GhostNet and The Shadow Network.
Yet Palantir is not exclusively used by governments or law enforcement agencies. The company’s data solution works equally as well in more pedestrian pursuits.
The International Consortium of Investigative Journalists uses Palantir to gain insight into the global trade and illegal trafficking of human tissue. And, as we mentioned before, the K2 Intelligence firm was employed by the SIPC to conquer the 20 terabytes of data in its case against Bernie Madoff. The leaked report quotes Jeremy Kroll, CEO and Co-founder of K2, saying that Palantir was able to construct a story around several key events in the Madoff saga in just a couple of hours.
In the business of dealing with some of the world’s most sensitive sets of data, secrecy is clearly important to Palantir’s success. This document likely only gives a glimpse into Palantir’s true capability and reach, especially since it was current just over a year and a half ago. There’s probably a great deal of Palantir information still out there, waiting to be discovered — More than a Madoff’s worth.
Health insurance companies are uniquely positioned to save the day in our ailing health system. Yes, you heard me correctly: health insurers.
Health insurers — or “payers” — are reviled nearly universally. Confused by “explanation of benefits” forms and denials of coverage and frustrated by rising deductibles, co-pays, and costs of care, consumers rank their experiences with health insurers below those with cable companies and internet service providers. Physicians and other care providers — who are constantly negotiating price of services and filling out piles of paperwork — don’t like payers much either.
All this makes insurers unlikely heroes. But we need someone to cut through the complexity of the current system, demand true value from providers, and create better options for consumers. Insurers increasingly look like the folks who can do the job and reinvent their business at the same time.
How? They can use their market power (they direct the bulk of health care dollars) and understanding of different consumer segments to create innovative products, services, and partnerships that address consumers’ needs. In the process, they can help move us all toward a low-cost, value-based health care system. Here are some specific ideas on what payers could do:
Act as true partners to value-based providers. Most payers today are piloting new economic models that pay providers not for the services they provide but for the value they create. Most, however, are neglecting a key opportunity: helping providers change their operating model. To succeed in value-based care, providers need data, analytics, smart clinical-care teams, and managerial support. Insurers are well-positioned to provide all this. They can also help providers become more efficient and assist them in navigating the tricky financial transition from fee-for-service to fee-for-value economics. Most important, insurers can help the very best provider organizations succeed by using them as the core of attractive, competitively priced insurance products.
Offer options for low-cost, convenient care. One area of waste in health care is the use of physician offices and hospital emergency departments to treat minor conditions such as sore throats, urinary infections, and allergies. Payers can make it easy for their members to get care 24/7 in more appropriate settings by partnering with retail, urgent care clinics, and telehealth providers. They can also offer the data connectivity needed to keep the consumer’s primary care provider in the loop. Oscar, the New York health insurance company launched last year, received fanfare in the press over its sleek offering, which includes unlimited phone and video calls with physicians and a “doctor on call” service that provides prescriptions by phone or e-visits. A number of retail pharmacy chains are also actively pursuing retail health and wellness clinics in stores to boost growth. Walmart has been piloting low-cost care clinics offering a $40 office visit that could dramatically reset the cost bar if scaled broadly.
Cover new wellness- and prevention-oriented treatments. Such options can serve as effective adjuncts to traditional benefits and encourage the trend toward more self-care. Aetna, for example, has offered mindfulness and yoga training to 6,000 of its employees. Its research shows that lower employee stress improved productivity by 69 minutes per week and gave an 11:1 return on investment. Similarly, articles in The New York Times, TIME, Scientific American, JAMA, and The Huffington Post cite growing evidence of the efficacy of meditation programs.
Explode the PPO model. Today the gold standard for health insurance is a preferred provider organization, a huge collection of doctors assembled to provide something for everyone but no special benefit to anyone. Insurers can do a better job for consumers and create real value by developing hassle-free mass customization. In this new model, consumers can choose from lifestyle-based curated options that offer trade-offs across risk level, health-savings options, primary-care models, alternative networks, network breadth, coaching and navigation programs, rewards programs, contract length, and incentive structures. Transparency tools and crowd-sourced reviews will spotlight value and multi-modal coordinated care delivery (think care teams that seamlessly work with telehealth providers, health coaches, and retail clinics) will help cut costs considerably. Consumers will be able to trade their own health engagement into benefit dollars and rewards that they can use seamlessly. While true à la carte insurance customization is not yet a reality, private exchange platforms are starting to provide a stepping stone to get there. For example, Maxwell Health, a new private exchange platform, presents a beautiful interface with lifestyle-focused packages that make product selection simple and tailored for you.
Sell convenience and personalized service. Most health care could hardly be less convenient. Now that consumers have unprecedented purchasing power (rise of public and private exchanges) and bear unprecedented costs (mounting high deductibles and premiums), they expect iPhone-like service. There is tremendous opportunity for payers to make the health care experience simpler and more supportive with online appointment scheduling, clear data and reviews, personalized suggestions, navigation apps with predictive decision support, reward programs, peer-to-peer support, and many other tools. Making the consumer experience better is smart for payers too. They can build stickier consumer relationships and generate new opportunities to address consumers’ growing health and lifestyle needs.
Power healthy behavior change. Some 50% of the determinants of health are driven by lifestyle and personal behaviors. Changing people’s behavior is a tall order but is necessary to improve health care. There are already examples of innovators that are succeeding, such as Omada Health with weight loss for pre-diabetics and Zipongo with healthy eating. We’ve only begun to deploy behavioral science, advanced wearable/monitoring technologies, and machine learning to understand the behaviors and motivations of different groups to predict and prevent acute events and connect people with the solutions that work best for them.
Serve as the bridge between new tools and consumers. In the first half of 2014,venture capital investment in digital health grew by 176%, spawning new consumer-centric companies with interesting approaches to consumer health. But there’s a chasm between these unscaled point solutions and the consumers who could use them. Payers can bridge the gap, using Amazon-style analytics and personalization to better understand consumer types and then connect them at the right place and time to the best-suited offerings. Better yet, payers don’t need to build the bridge themselves: A growing set of powerful consumer-engagement platforms (e.g., WellTok and Optum’s Rally) are moving along this path.
Payers have economic incentives to do everything I’ve described. The Affordable Care Act puts limits on the margins they can earn from their traditional business (Oliver Wyman estimates payer margins may shrink by a third), and an evolving marketplace means that they will face significantly more competition — from each other, health care providers, and new entrants that see an opportunity to capture growth in a $3 trillion market. The options I’ve described would let payers move into non-regulated markets and potentially generate revenue from discretionary consumer spending — a growing pot of money they have not accessed much.
Can they win consumers over? One advantage of being in an industry people don’t like is that there are many opportunities to pleasantly surprise the consumer. The good news is that the things that will make consumers happy — more convenience, customization, support for doctors, coordination of care — can all contribute to attractive new business opportunities while making the health care system more efficient, effective, humane, and sustainable.
Sukanya Soderland is a partner in Oliver Wyman’s Health and Life Sciences practice and a leader in the firm’s Health Innovation Center.
Just three surgeons have been named as performing more poorly than they should be under new data comparing the death rates of 5,000 surgeons in England.
Data published today on a central NHS website has been hailed as part of a “world leading transparency drive”.
The figures show that almost every surgeon in the country has been found to be operating within “the expected range” of performance.
NHS England said the findings should reassure the public.
But critics questioned whether the limits were set too widely, allowing surgeons to be labelled as “okay” when their performance was worryingly poor.
Just three surgeons were named today as “outliers” – meaning that their death rates were found to be significantly worse than average over the periods examined.
Dynesh Rittoo, a vascular surgeon at the Royal Bournemouth and Christchurch Hospitals foundation trust was found to have a risk-adjusted mortality rate of 10.4 per cent over three years for carotid endarterectomies – a procedure to reduce the risk of stroke. The national average for the same procedure was 2 per cent.
In a statement agreed by the consultant, the trust said: “The overall 3-year rate for Mr Rittoo reflects a series of strokes in 2011. The rate of strokes / deaths within 30 days for Mr Rittoo between October 2011 and September 2013 is 6.4 per cent, and this rate is consistent with the outcomes of other vascular surgeons.”
Jonathan Hyde, a heart surgeon at Royal Sussex County Hospital, was found to have a a risk-adjusted hospital mortality rate of 6.63 per cent over a three-year period in which he performed more than 500 operations on adults.
Mr Hyde said he had taken action to improve his mortality rates, with more recent figures suggesting a significant improvement.
He said: “The data shown reflect higher mortality rates from my practice predominantly in the years 2011 and 2012 and therefore refer to outcomes from more than 18 months ago.
“In the light of these outcomes, I have reviewed my practice in detail with the support of an Individual Review from the Royal College of Surgeons. The mortality for my surgery for the period April 2013 to October 2014 has been 1.8 per cent prior to any adjustment for individual patient risk.”
Jeff Garner, a colorectal surgeon at Rotherham NHS Foundation trust, with a mortality rate of 14 per cent for surgery over the 18 months examined. Of 50 patients treated by Mr Garner, six died.
The trust said: “This Trust has acknowledged its outlier status and that of one of its surgeons. It has confirmed that measures have been taken to improve outcomes with a comprehensive overhaul of the colorectal service in 2012-2013 and close scrutiny of any deaths to identify potential surgical or system failings. The cumulative nature of data reporting means that it is likely to be at least another year before the Trust and surgeon cease to be outliers.”
Roger Taylor, co-founder of data analysts Dr Foster, said it was “misleading” to suggest that there were only three surgeons in the country who were performing significantly worse than the rest.
“If you asked any surgeon whether they thought there were only three in the country who were significantly worse than the rest of them, I think they would laugh,” he said.
He criticised the way the analysis had been done, which he said appeared designed to hide poor performance
Mr Taylor said: “What is being said is that this will help people to identify good and poor performing individuals. This actually looks like it has been designed to avoid identifying good or poor outcomes.”
He said surgeons should not have been allowed to come up with their own methods to assess performance, which had set limits too broadly. He also said it would have been more sensible to examine performance over longer periods, where trends would be more likely to be revealed.
Professor Sir Bruce Keogh, NHS Medical Director said: “This represents another major step forward on the transparency journey. It will help drive up standards, and we are committed to expanding publication into other areas.”
“The results demonstrate that surgery in this country is as good as anywhere in the western world and, in some specialities, it is better. The surgical community in this country deserves a great deal of credit for being a world leader in this area.”
Which surgeon you get matters — a lot. But how do we know who the good ones are?
“You can think of surgery as not really that different than golf.” Peter Scardino is the chief of surgery at Memorial Sloan Kettering Cancer Center (MSK). He has performed more than 4,000 open radical prostatectomies. “Very good athletes and intelligent people can be wildly different in their ability to drive or chip or putt. I think the same thing’s true in the operating room.”
The difference is that golfers keep score. Andrew Vickers, a biostatistician at MSK, would hear cancer surgeons at the hospital having heated debates about, say, how often they took out a patient’s whole kidney versus just a part of it. “Wait a minute,” he remembers thinking. “Don’t you know this?”
“How come they didn’t know this already?”
In the summer of 2009, he and Scardino teamed up to begin work on a software project, called Amplio (from the Latin for “to improve”), to give surgeons detailed feedback about their performance. The program—still in its early stages but already starting to be shared with other hospitals — started with a simple premise: the only way a surgeon is going to get better is if he knows where he stands.
Vickers likes to put it this way. His brother-in-law is a bond salesman, and you can ask him, How’d you do last week?, and he’ll tell you not just his own numbers, but the numbers for his whole group.
Why should it be any different when lives are in the balance?
Andrew Vickers
The central technique of Amplio, using outcome data to determine which surgeons were more successful, and why, takes on a powerful taboo. Perhaps the longest-standing impediment to research into surgical outcomes — the reason that surgeons, unlike bond salesmen (or pilots or athletes), are so much in the dark about their own performance — are the surgeons themselves.
“Surgeons basically deeply believe that if I’m a well-trained surgeon, if I’ve gone through a good residency program, a fellowship program, and I’m board-certified, I can do an operation just as well as you can,” Scardino says. “And the difference between our results is really because I’m willing to take on the challenging patients.”
It is, maybe, a vestige of the old myth that anyone ordained to cut into healthy flesh is thereby made a minor god. It’s the belief that there are no differences in skill, and that even if there were differences, surgery is so complicated and multifaceted, and so much determined by the patient you happen to be operating on, that no one would ever be able to tell.
Vickers said to me that after several years of hearing this, he became so frustrated that he sat down with his ten-year-old daughter and conducted a little experiment. He searched YouTube for “radical prostatectomy” and found two clips, one from a highly respected surgeon and one from a surgeon who was rumored to be less skilled. He showed his daughter a 15second clip of each and asked, “Which one is better?”
“That one,” she replied right away.
When Vickers asked her why, “She looked at me, like, can’t you tell the difference? You can just see.”
Would you want to be cut by this surgeon?Or this one?
A remarkable paper published last year in the New England Journal of Medicine showed that maybe Vickers’s daughter was onto something.
In the study, run by John Birkmeyer, a surgeon who at the time was at the University of Michigan, bariatric surgeons were recruited from around the state of Michigan to submit videos of themselves doing a gastric bypass operation. The videos were sent to another pool of bariatric surgeons to be given a series of 1-to-5 rating on factors such as “respect for tissue,” “time and motion,” “economy of movement” and “flow of operation.”
The study’s key finding was that not only could you reliably determine a surgeon’s skill by watching them on video — skill was nowhere near as nebulous as had been assumed — but that those ratings were highly correlated with outcomes: “As compared with patients treated by surgeons with high skill ratings, patients treated by surgeons with low skill ratings were at least twice as likely to die, have complications, undergo reoperation, and be readmitted after hospital discharge,” Birkmeyer and his colleagues wrote in the paper.
You can actually watch a couple of these videos yourself [see above]. Along with the overall study results, Birkmeyer published two short clips: one from a highly rated surgeon and one from a low-rated surgeon. The difference is astonishing.
You see the higher-rated surgeon first. It’s what you always imagined surgery might look like. The robot hands move with purpose — quick, deliberate strokes. There’s no wasted motion. When they grip or sew or staple tissue, it’s with a mix of command and gentle respect. The surgeon seems to know exactly what to do next. The way they’ve set things up makes it feel roomy in there, and tidy.
Watching the lower-rated surgeon, by contrast, is like watching the hidden camera footage of a nanny hitting your kid: it looks like abuse. The surgeon’s view is all muddled, they’re groping aimlessly at flesh, desperate to find purchase somewhere, or an orientation, as if their instruments are being thrashed around in the undertow of the patient’s guts. It’s like watching middle schoolers play soccer: the game seems to make no sense, to have no plot or direction or purpose or boundary. It’s not, in other words, like, “This one’s hands are a bit shaky,” it’s more like, “Does this one have any clue what they’re doing?”
It’s funny: in other disciplines we reserve the word “surgical” for feats that took a special poise, a kind of deftness under pressure. But the thing we maybe forget is that not all surgery is worthy of the name.
Vickers is best known for showing exactly how much variety there is, plotting, in 2007, the so-called “learning curve” for surgery: a graph that tracks, on one axis, the number of cases a surgeon has under his belt, and on the other, his recurrence rates (the rate at which his patients’ cancer comes back).
As surgeons get more experience, their patients do better. This “learning curve” shows patients’ 5 year cancer-free rates rise with procedure volume.
He showed that in incidents of prostate cancer that haven’t spread beyond the prostate — so-called ‘organ-confined’ cases — the recurrence rates for a novice surgeon were 10 to 15%. For an experienced surgeon, they were less than 1%. With recurrence rates so low for the most experienced surgeons, Vickers was able to conclude that in organ-confined cancer cases, the onlyreason a patient would recur is “because the surgeon screwed up.”
There’s a large literature, going back to a famous paper in 1979, finding that hospitals with higher volumes of a given surgical procedure have better outcomes. In the ’79 study it was reported that for some kinds of surgery, hospitals that saw 200 or more cases per year had death rates that were 25% to 41% lower than hospitals with lower volumes. If every case were treated at a high-volume hospital, you would avoid more than a third of the deaths associated with the procedure.
But what wasn’t clear was why higher volumes led to better outcomes. And for decades, researchers penned more than 300 studies restating the same basic relationship, without getting any closer to explaining it. Did low-volume hospitals end up with the riskiest patients? Did high-volume hospitals have fancier equipment? Or better operating room teams? A better overall staff? An editorial as late as 2003 summarized the literature with the title, “The Volume–Outcome Conundrum.”
A 2003 paper by Birkmeyer, “Surgeon volume and operative mortality in the United States,” was the first to offer definitive evidence that the biggest factor determining the outcome of many surgical procedures — the hidden element that explained most of the variation among hospitals — was the procedure volume not of the hospital, but of the individual surgeons.
“In general I don’t think anyone was surprised that there was a learning curve,” Vickers says. “I think they were surprised at what a big difference it made.” Surprised, maybe, but not moved to action. “You may think that everyone would drop what they were doing,” he says, “and try and work out what it is that some surgeons are doing that the other ones aren’t… But things move a lot more slowly than that.”
Tired of waiting, Vickers started sharing some initial ideas with Scardino about the program that would become Amplio. It would give surgeons detailed feedback about their performance. It would show you not just your own results, but the results for everyone in your service. If another surgeon was doing particularly well, you could find out what accounted for the difference; if your own numbers dropped, you’d know to make an adjustment. Vickers explains that they wanted to “stop doing studies showing surgeons had different outcomes.”
“Let’s do something about it,” he told Scardino.
Dr. Scardino
The first time I heard about Amplio was on the third floor of the Chrysler Building, in a room they called the Innovation Lab — the very room you’d point to if the Martians ever asked you what a 125-year old bureaucracy looks like. As I arrived, the receptionist was trying to straighten up a small mess of papers, post-its, cookies, and coffee stirrers. “The last crowd had a wild time,” she said. Every surface in the room was gray or off-white, the color of questionable eggs. It smelled like hospital-grade hand soap.
The people who filed in, though, and introduced themselves to each other (this was a summit of sorts, a “Collaboration Meeting” where different research groups from around MSK shared their works in progress) looked straight out of a well-funded biotech startup. There was a Fulbright scholar; a double-major in biology and philosophy; a couple of epidemiologists; a mathematician; a master’s in biostats and predictive analytics. There were Harvards, Cals, and Columbias, bright-eyed and sharply dressed.
Vickers was one of the speakers. He’s in his forties but he looks younger, less like an academic than a seasoned ski instructor, a consequence, maybe, of the long wavy hair, or the well-worn smile lines around his eyes, or this expression he has that’s like a mix of relaxed and impish. He leans back when he talks, and he talks well, and you get the sense that he knows he talks well. He’s British, from north London, educated first at Cambridge and then, for his PhD in clinical medicine, at Oxford.
The first big task with Amplio, he said, was to get the data. In order for surgeons to improve, they have to know how well they’re doing. In order to know how well they’re doing, they have to know how well their patients are doing. And this turns out to be trickier than you’d think. You need an apparatus that not only keeps meticulous records, but keeps them consistently, and throughout the entire life cycle of the patient.
That is, you need data on the patient before the operation: How old are they? What medications are they allergic to? Have they been in surgery before? You need data on what happened during the operation: where’d you make your incisions? how much blood was lost? how long did it take?
And finally, you need data on what happened to the patient after the operation — in some cases years after. In many hospitals, followup is sporadic at best. So before the Amplio team did anything fancy, they had to devise a better way to collect data from patients. They had to do stuff like find out whether it was better to give the patient a survey before or after a consultation with their surgeon? And what kinds of questions worked best? And who were they supposed to hand the iPad to when they were done?
Only when all these questions were answered, and a stream of regular data was being saved for every procedure, could Amplio start presenting something for surgeons to use.
A screen in Amplio shows how a surgeon’s patients are doing against their colleagues’
After years of setup, Amplio now is in a state where it can begin to affect procedures. The way it works is that a surgeon logs into a screen that shows where they stand on a series of plots. On each plot there’s a single red dot sitting amid some blue dots. The red dot shows your outcomes; the blue dots show the outcomes for each of the other surgeons in your group.
You can slice and dice different things you’re interested in to make different kinds of plots. One plot might show the average amount of blood lost during the operation against the average length of the hospital stay after it. Another plot might show a prostate patient’s recurrence rates against his continence or erectile function.
There’s something powerful about having outcomes graphed so starkly. Vickers says that there was a surgeon who saw that they were so far into the wrong corner of that plot — patients weren’t recovering well, and the cancer was coming back — that they decided to stop doing the procedure. The men spared poor outcomes by this decision will never know that Amplio saved them.
It’s like an analytics dashboard, or a leaderboard, or a report card, or… well, it’s like a lot of things that have existed in a lot of other fields for a long time. And it kind of makes you wonder, why has it taken so long for a tool like this to come to surgeons?
The answer is that Amplio has cleverly avoided the pitfalls of some previous efforts. For instance, in 1989, New York state began publicly reporting the mortality rates of cardiovascular surgeons. Because the data was “risk-adjusted”—an unfavorable outcome would be considered less bad, or not counted at all, if the patient was at risk to begin with — surgeons started pretending their patients were a lot worse off than they were. In some cases, they avoided patients who looked like goners. “The sickest patients weren’t being treated,” Vickers says. One investigation into why mortality in New York had dropped for a certain procedure, the coronary artery bypass graft, concluded that it was just because New York hospitals were sending the highest-risk patients to Ohio.
Vickers wanted to resist such gaming. But the answer is not to quit adjusting for patient risk. After all, if a given report says that your patients have 60% fewer complications than mine, does that mean that you’re a 60% better surgeon? It depends on the patients we see. It turns out that maybe the best way to prevent gaming is just to keep the results confidential. That sounds counter to a patient’s interests, but it’s been shown that patients actually make little use of objective outcomes data when it’s available, that in fact they’re much more likely to choose a surgeon or hospital based on reputation or raw proximity.
With Amplio, since patients, and the hospital, and even your boss are blinded from knowing whose results belong to whom, there’s no incentive to fudge risk factors or insist that a risk factor’s weight be changed, unless you think it’s actually good for the analysis.
That’s why Amplio’s interface for slicing and dicing the data in multiple ways matters, too. Feedback systems in the past that have given surgeons a single-dimensional report — say, they only track recurrence rates — have failed by creating a perverse incentive to optimize along just that one dimension, at the expense of all the others. Another reminder that feedback is, like surgery itself, fraught with complication: if you do it wrong, it can be worse than useless.
Every member of the Amplio team I spoke to stressed this point over and over again, that the system had been painstakingly built from the “bottom up” — tuned via detailed conversations with surgeons (“Are you accounting for BMI? What if we change the definition of blood loss?”) — so that the numbers it reported would be accurate, and risk-adjusted, and multidimensional, and credible. Because only then would they be actionable.
Karim Touijer, a surgeon at MSK who has used Amplio, explains the system’s chief benefit is the fact that you can vividly see how you’re doing, and that someone else is doing better. “When you set a standard,” he says, “the majority of people will improve or meet that standard. You tend to shrink the outliers. If I’m an outlier, if my performance leaves something to be desired, then I can go to my colleagues and say what is it that you’re doing to get these results?” Touijer sees this as the gradual standardization of surgery: you find the best performers, figure out what makes them good, and spread the word. He said that already within his group, because the conversations are more tied to outcomes, they’re talking about technique in a more objective way.
In fact, he says, as a result of Amplio he and his team have devised the first randomized clinical trial that is solely dedicated to surgical maneuvers.
Touijer specializes in the radical prostatectomy, considered one of the most complex and delicate operations in all of surgical practice. The procedure — in which a patient’s cancerous prostate is entirely removed — is highly sensitive to an individual surgeon’s skill. The reason is that the cancer ends up being very close to the nerves that control sexual and urinary function. It’s an operation unlike, say, kidney cancer, where you can easily go widely around the cancer. If you operate too far around the prostate, you could easily damage the rectum, the bladder, the nerves responsible for erection, or the sphincter responsible for urinary control. “It turns out that radical prostatectomy is very, very intimately influenced by surgical technique,” Touijer says. “One millimeter on one side or less than a millimeter on the other can change the outcome.”
Option B in the first A/B test for surgery: “A second bite is taken deeply into the fascia of the lateral pelvic fascia”
There’s a moment during the procedure where the surgeon has to decide whether to make a particular stitch. Some surgeons do it, some don’t; we don’t yet know which way is better. In the randomized trial, if the surgeon doesn’t have a compelling reason to pick one of the two alternatives, he lets the computer decide randomly for him. With enough patients, it should be possible to isolate the effect of that one decision, and to find out whether the extra stitch leads to better outcomes. The beauty is, since the outcomes data was already being tracked, and the patients were already going to have the surgery, the trial costs almost nothing.
If you’ve worked on the web, this model of rapid, cheap experimentation probably sounds familiar: what Touijer is describing is the first A/B test for surgery. As it turns out this particular test didn’t yield significant results. But several other tests are in the works, and some may improve some specific surgical techniques—improving the odds for all patients.
In Better, Atul Gawande argues that when we think of improving medicine, we always imagine making new advances, discovering the gene responsible for a disease, and so on — and forget that we can simply take what we already know how to do, and figure out how to do it better. In a word, iterate.
“But to do that,” Scardino says, “we have to measure it, we have to know what the results are.”
Scardino describes how when laparascopy was first becoming an option for radical prostatectomy, there was a lot of hype. “The company and many doctors who were doing it immediately claimed that it was safer, had better results, was more likely to cure the cancer and less likely to have permanent urinary or sexual problems.” But, he says, the data to support it were weak, and biased. “We could see in Amplio early on that as people started doing robotic surgery, the results were clearly worse.” It took time for them to hit par with the traditional open procedure; it took time for them to get better.
After a pilot among prostate surgeons, Amplio spread quickly to other services within MSK, including for kidney cancer, bladder cancer and colorectal cancer. Vickers’s team has been working with other hospitals — including Columbia in New York, the Barbara Ann Karmanos Cancer Institute in Michigan, and the MD Anderson Cancer Center in Texas — to slowly begin integrating with their systems. But it’s still early days: even within their own hospital, surgeons were wary of Amplio. It took many conversations, and assurances, to convince them that the data were being collected for their benefit — not to “name and shame” bad performers.
We know what happens when performance feedback goes awry — similar efforts to “grade” American schoolteachers, for instance, have perhaps generated more controversy than results. To do performance feedback well requires patience, and tact, and an earnest imperative to improve everyone’s results, not just to find the negative outliers. But Vickers believes that enough surgeons have signed on that the taboo has been broken at MSK. And results are bound to flow from that.
It’s all about trust. Remember the Birkmeyer study that compared surgeons using videos? It was only possible because Birkmeyer had built up relationships by way of a previous outcomes experiment in Michigan that meticulously protected data. “That’s a question that we get really frequently,” Birkmeyer told me when we spoke about the paper. “How on earth did we ever pull that study off?” The key, he says, is that years of research with these surgeons had slowly built goodwill. When it came time to make a big ask, “the surgeons were at a place where they could trust that we weren’t gonna screw them.”
Amplio will no doubt have to be able to say the same thing, if it’s to spread beyond the country’s best research cancer centers into the average regional hospital.
In 1914, a surgeon at Mass General got so fed up with the administration, and their refusal to measure outcomes, that he created his own private hospital, “the End Result Hospital,” where detailed records were to be kept of every patient’s “end results.” He published the first five years of his hospital’s cases in a book that became one of the founding documents of evidence-based medicine.
“The Idea is so simple as to seem childlike,” he wrote, “but we find it ignored in all Charitable Hospitals, and very largely in Private Hospitals. It is simply to follow the natural series of questions which any one asks in an individual case: What was the matter? Did they find it out beforehand? Did the patient get entirely well? If not — why not? Was it the fault of the surgeon, the disease, or the patient? What can we do to prevent similar failures in the future?”
It might finally be time for that simple, “childlike” concept to reach fruition. It’s like Vickers said to me one night in early November, as we were discussing Amplio, “Having been in health research for twenty years, there’s always that great quote of Martin Luther King: The arc of history is long, but it bends towards justice.”
A lack of infrastructure in Australia to care for more people in a community, rather than a hospital, costs us dearly. Photo: Louie Douvis
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