Monthly Archives: June 2014

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Duckett: Has health reform failed? Yes

A big issue for the health system in Australia is that no-one’s in charge. Not the Commonwealth, not the states, not the private health insurance funds. Most provision is private: general practitioners are increasingly employed by for-profit chains, and before that, small business people. They respond to incentives designed by the Commonwealth government.

http://theconversation.com/did-the-health-reform-process-fail-now-well-never-know-27921

Did the health reform process fail? Now we’ll never know

Abandoning health reforms will undoubtedly lead to worse performance, including longer waiting times, across the health system. AAP Image/Quentin Jones

Yesterday was a sorry day in the long history of health reform in Australia. The Council of Australian Governments (COAG) Reform Council issued its five year score-keeper’s report on health reform progress. It will be the last such report, since the COAG Reform Council has been sacrificed on the altar of savings in the May budget, and we will no longer know how our governments are performing.

The COAG Reform Council paints some lipstick on the pig but overall reform results are poor in the health system. Compared to last year, Australians are waiting marginally longer for elective surgery, longer for community support in the home, and dramatically longer to get into residential aged care.

On the upside, we’re living slightly longer, having fewer heart attacks and the incidence of some cancers has reduced. The five-year trends for performance paint a similar picture to the year-on-year results.

It’s easy to conclude that the health reform process was a waste of time and money. But this is shortsighted. Many of the structural reforms focused on building the foundations of a health system that was on the verge of being able to deliver real improvements in patient care.

Slow road to reform

Kevin Rudd’s gab-fest of health reform talk in 2009 and early 2010 led to an alphabet soup of new health agencies, some investment in parts of the health system, more data in the public domain than we’ve ever seen but precious little in terms of real on-the-ground improvements.

But there were some important exceptions. The Rudd-appointed National Health and Hospitals Reform Commission identified a gap in availability of rehabilitation beds in the system. Without adequate rehabilitation care people were ending up in nursing homes when they could have been at home. Reform money helped to address that gap, although that funding was abruptly terminated in the 2014 budget.

Funding was also provided for better prevention programs and to reward improvements in waiting times where they occurred. Medicare Locals were created to provide a platform for improvements in primary care such as better after-hours services.

Running a health system is hard, improving it is even harder. But we have to improve every day just to stand still. The new treatments that are introduced every week put pressure on the health dollar. These new treatments, though, mean we’re living longer – so we get something for the extra money.

A big issue for the health system in Australia is that no-one’s in charge. Not the Commonwealth, not the states, not the private health insurance funds. Most provision is private: general practitioners are increasingly employed by for-profit chains, and before that, small business people. They respond to incentives designed by the Commonwealth government.

The pathology and radiology markets are also highly concentrated corporatised businesses. Around one-third of hospital beds are in private hospitals, and most of those are for-profit businesses as well.

Abolishing the foundations

The health reform process mainly concentrated on two aspects of the system: primary care and public hospitals. Primary care reform was mainly effected through the creation of Medicare Locals and GP Super Clinics.

Both were good ideas but flawed in implementation: some Super Clinics are still not open five years after the policy got underway. Medicare Locals were over-hyped by the previous government, wrapped up in red tape by the Commonwealth Health Department and as a result of the budget are being abolished and replaced by new organisations.

Public hospital reform had two elements. In most states it included increased local autonomy through introduction of local boards, and increased services with expanded rehab being the best example. At the national level it included a new alignment of Commonwealth and state interests in controlling hospital costs.

From June 1, 2014, the Commonwealth will meet 45% of the costs of increased hospital activity, but only up to an independently determined “efficient price”. This is a good reform, because could have ended the blame game between Commonwealth and states over money by locking the former into funding increased health state health spending. But these changes will be undone in 2017.

So come 2017, most evidence of health reform will have vanished. There will be some ongoing structures and services, but the big aspirations to address the big problems will have fizzled out.

The problems won’t go away, however. Innovation and system reform will still be required. If anyone is around to issue the next score-keeper’s report it will undoubtedly show worse performance, including longer waiting times, across the health system. There’ll then be more calls for reform and the whole cycle will start again, but with wasted years in the meantime.

data saving lives, health market quality, healthcare, policy, politics, rapid learning health systems

Scruitiny starts to land in healthcare…

“When hospital administrators meet with doctors, we talk in great platitudes, and it’s easy for physicians to say, ‘Well, my patients are sicker.’ Data takes out the emotion. It can be a moment of shock.“

They key to delivering information unemotionally is using a physician leader as the messenger. 

“The important mental transition that has to occur within physicians is, ‘This is about a team concept and approach to care. It’s not just about me and why I think is best for my patient.’ That’s a problem some physicians have.”

http://www.healthleadersmedia.com/print/PHY-305709/Physicians-Feel-Reforms-Tight-Scrutiny

Physicians Feel Reform’s Tight Scrutiny

Jacqueline Fellows, for HealthLeaders Media , June 19, 2014

Thanks to healthcare reform, there are now more eyes on how doctors treat their patients and more opinions on how they should be treating them. But one physician leader says the pressure doesn’t necessarily mean that doctors have to be on the defensive.

All working professionals, from writers to physicians, have a preference for the way their work gets done, but a doctor’s penchant for how he or she cares for a patient is increasingly coming under scrutiny.

First, there are cost and quality pressures from hospitals, health systems, and payers as a result of the value-based healthcare transition that affects how physicians practice, not to mention public pressure on how much physicians get paid with the recent release of Medicare payment data.

Then there are the efforts to standardize patient care among providers in hospitals, group practices, and health systems in an effort to improve quality.

All of it leads to more eyes (and opinions) on how doctors care for patients, which can be uncomfortable.

Kevin Wheelan, MD, chief of staff and co-medical director of cardiology for Baylor Heart and Vascular Hospital, a joint venture hospital within Dallas-based Baylor Scott & White Health, says the pressure doesn’t necessarily mean that doctors have to be on the defensive, or have an adversarial relationship with leaders.

Rather, Wheelan looks at the issue through a different lens. Without uniformity of care, quality can suffer, and patients leave confused. “Ten different sets of discharge instructions sets up [the hospital] for inconsistency,” he says. “If the patient doesn’t leave the hospital with a well-articulated game plan, that could lead to an unscheduled visit to the ER.”

That’s code for readmissions and possible penalties. Reducing both requires better communication with the patient, which Wheelan says has improved at BHVH with better and easier-to-understand discharge instructions.

“The tools have improved in terms of more detailed collateral materials as a resource for patients to refer back to,” says Wheelan.

In addition, Wheelan says BHVH has also enhanced medication reconciliation by having both a nurse and a physician review what medicine a patient is taking at home that could interfere with medication prescribed upon release.

The post-discharge appointment is also a more focused discussion, says Wheelan.

“Instead of telling a patient, ‘See you within 30 days,’ for example, the goal is to have a follow up appointment scheduled, so it’s not a nebulous concept of when they’re returning.”

Follow-up phone calls also help reduce readmissions and anxiety from patients. The phone calls are also a data mining exercise that shows variance among physicians. It’s not intended to be an exercise in checking up on physicians, but it has helped standardize care and reinforce a culture of teamwork.

“We keep track of all of these phone calls,” says Wheelan. “We have a document typed up, blinded to the patients’ names, and those results are provided back to the physician leader and the physician practices for an opportunity for improvement issue.”

Using data to show a variance can take some of the sting out of a difficult conversation with a physician. It helps, says Wheelan, that physicians see exactly what a patient is saying.

“It gives [physicians] a different insight,” he says. “The doctors get to see types of concerns the patients have.”

Wheelan says BHVH’s system isn’t not perfect. There are still difficulties with weekend discharges, but he says setting a specific follow-up appointment time is the biggest change since BHVH opened in 2002. But it didn’t happen easily because of physician preference.

“It’s an issue of compromise,” says Wheelan. “You have a group of physicians who say, ‘I need to see a patient two days post-op,’ and another group who says they need five days. So we have to come to an agreement that we will see the patient within 2–5 days.”

Getting standardization among physicians is difficult, admits Wheelan, but it’s also an opportunity for physician leaders to emerge because “someone has to be a champion,” willing to track down the other physicians and get buy in for clinical protocols.

Using data to accompany a potentially hard conversation about performance is an approach that is also used at Southwest General Health Center, a 354-bed hospital in Middleburg Heights, OH.

“Physicians tend to be logical, numbers-driven people,” says Jill Barber, director of managed care operations and revenue integrity for Southwest General. “When hospital administrators meet with doctors, we talk in great platitudes, and it’s easy for physicians to say, ‘Well, my patients are sicker.’ Data takes out the emotion. It can be a moment of shock.”

Also like BHVH, Southwest General uses verbatim comments from patients to give physicians insight into patient satisfaction. “By sharing with them the actual comments, it brings it home,” says Barber.

They key to delivering information unemotionally is using a physician leader as the messenger. It’s what BHVH and Southwest General rely on because it is peer-to-peer, and more “collegial” rather than punitive, says Barber.

Physicians also have to think differently in a value-based era of healthcare, explains Wheelan.

“The important mental transition that has to occur within physicians is, ‘This is about a team concept and approach to care. It’s not just about me and why I think is best for my patient.’ That’s a problem some physicians have.”

It’s a problem they’ll likely have to grow out of, too, in order to withstand the pressure, opinions, and eyes that are watching.

Jacqueline Fellows is an editor for HealthLeaders Media.

healthy habits, nutrition, policy, politics

Marion does fish politics

 

Fish politics: The FDA’s updated policy on eating fish while pregnant

JUN172014

Fish politics: The FDA’s updated policy on eating fish while pregnant

Eating fish presents difficult dilemmas (I evaluate them in five chapters of What to Eat).

This one is about asking pregnant women to weigh the benefits of fish-eating against the hazards of their toxic chemical contaminants to the developing fetus.

The Dietary Guidelines tell pregnant women to eat 2-to-3 servings of low-mercury fish per week (actually, it’s methylmercury that is of concern, but the FDA calls it mercury and I will too).

But to do that, pregnant women have to:

  • Know which fish are low in mercury
  • Recognize these fish at the supermarket, even if they are mislabeled (which they sometimes are).

Only a few fish, all large predators, are high in mercury.  The FDA advisory says these are:

  • Shark
  • Swordfish
  • King Mackerel
  • Tilefish

What?  This list leaves off the fifth large predator: Albacore (white) tuna.  This tuna has about half the mercury as the other four, but still much more than other kinds of fish.

The figure below comes from the Institute of Medicine’s fish report.  It shows that fish highest in omega-3 fatty acids, the ones that are supposed to promote neurological development in the fetus and cognitive development in infants, are also highest in mercury.

fish

White tuna is the line toward the bottom.  The ones in the blue boxes are all much lower in omega-3s and in mercury except for farmed Atlantic salmon (high in omega-3s, very low in mercury).

What’s going on here?

  • Tuna producers know you can’t tell the difference between white and other kinds of tuna and don’t want you to stop eating tuna during pregnancy.
  • The data on the importance of eating fish to children’s cognitive development are questionable (in my opinion).  The studies are short term and it’s difficult to know whether the small gains in early cognitive development that have been reported make any difference a few months later.
  • The FDA must be under intense pressure to promote fish consumption.

I think it is absurd to require pregnant women to know which fish to avoid.  In supermarkets, fish can look pretty much alike and you cannot count on fish sellers to know the differences.

Other dilemmas:

  • Even smaller fish have PCBs, another toxin best avoided by pregnant women, if not everyone.
  • The world’s seafood supply is falling rapidly as a result of overfishing.
  • Half of the mercury in seafood derives from emissions from coal-burning power plants.  The best way to reduce mercury in fish is to clean up the emissions from those plants, but plant owners want to avoid the expense.

That’s fish politics, for you.

The FDA documents:

cool, family matters, healthy habits, management and leadership, meaning, musings, quotes & aphorisms, storytelling

Navy Seal on changing the world…

According to Admiral William H. McRaven, if you want to change the world you must:

  1. start each day with a task completed
  2. find someone to help you through life
  3. respect everyone
  4. know that life is not fair
  5. know that you will fail often
  6. take some risks
  7. step up when the times are the toughest
  8. face down the bullies
  9. lift up the down trodden
  10. never, ever give up

healthy habits, nutrition, policy

On how good broccoli is

 

http://www.theatlantic.com/health/archive/2014/06/the-only-reason-anyone-would-eat-broccoli/372899/

Broccoli Loves Us

New cancer-prevention research says that consuming broccoli sprouts makes people excrete benzene in their urine, mitigating effects of breathing polluted air.
Nick Saltmarch/Flickr

What are you doing with the benzene you inhale? Just absorbing it, stocking up on sleepiness, dizziness, anemia, possibly leukemia? Or are you taking control and expunging it in your urine?

This week in the journal Cancer Prevention Research, scientists from Johns Hopkins and China’s Qidong Liver Cancer Institute report that daily consumption of a half-cup of “broccoli-sprout beverage”—a tea made with broccoli sprouts—produced rapid, sustained, high-level excretion of benzene in research subjects’ urine. Their conclusion, building on prior research, is that broccoli helps the human body break down benzene and excrete its byproducts. As benzene is a known human carcinogen commonly found in polluted air in both urban and rural areas, voiding it is an unmitigated virtue.

The broccoli-sprout beverage also increased the levels of the lung irritant acrolein, another common air pollutant, in the subjects’ urine.

So every alt-juice shop that sells a $14 broccoli-sprout smoothie on its “cleansing” merits is technically not entirely lying.

The broccoli-sprout beverage is understood to be a vehicle for the compound sulforaphane, which has been shown to have cancer-preventive qualities in animal studies, apparently by activating a molecule called NRF2 that enhances cells’ abilities to adapt to environmental toxins. In another study earlier this year, sulforaphane-rich broccoli sprout preparations decreased people’s nasal allergic responses to diesel exhaust particles.

The researchers found that among participants who drank the broccoli-sprout beverage, excretion of benzene increased 61 percent—beginning the first day and continuing throughout the 12-week study. Excretion of acrolein increased by 23 percent.

Outdoor air pollution is associated with cardiorespiratory mortality, chronic obstructive pulmonary disease, lung cancer, and overall decreased lung function. According to the World Health Organization, air pollution kills around seven million people every year. It might seem absurd to suggest putting the onus on individual dietary choices, but that’s basically what’s happening here. Environmental researchers call it chemoprevention. A quarter of the world is breathing unsafe air, and while government officials are hard at work implementing regulatory policies to improve air quality and reduce reliance on fossil fuels, which they surely are, we get to eat more broccoli.

“This study points to a frugal, simple, and safe means that can be taken by individuals,” said lead researcher Thomas Kensler, a professor at Johns Hopkins Bloomberg School of Public Health, in a press statement, “to possibly reduce some of the long-term health risks associated with air pollution.”

Regular broccoli also contains sulforaphane, though in considerably lower quantities than the sprouts studied here, which the researchers found to be “the maximum tolerated dose.”

“The more bitter your broccoli, perhaps the better,” Kensler told The Wall Street Journal, adding that one would have to consume roughly 1.5 cups of broccoli every day to get the same amount consumed in this study—even more if it’s boiled, which is just no way to prepare broccoli.

Chemoprevention could empower people who live in areas with high levels of air pollution, and this study will provide leverage for broccoli-pushing parents everywhere. “Eat your broccoli, child, or the air will get you. Chemicals that the corporations put in the air will give you cancer. Finish it. The air is coming for you. Finish your broccoli. Eat your broccoli. Don’t you. No. Don’t you talk to me about policy reform. The only person you can count on in this world is yourself. Swallow. Eat it.”

healthy habits, quantified self

Non-invasive glucose monitoring

 

 

http://www.fiercemobilehealthcare.com/story/researchers-develop-biometric-watches-glucose-monitoring-pulse-tracking/2014-06-14

Researchers develop biometric watches for glucose monitoring, pulse tracking

June 14, 2014 | By 

Research papers published in The Optical Society’s journal Biomedical Optics Express, detail how the biometric watches rely on what’s called a “speckle” light effect, which is the result of laser light hitting uneven surfaces or the scatter of laser light from an opaque object.

The glucose biometric system, which monitors the bloodstream for glucose and hydration, represents a groundbreaking technology, according to its research team.

“Glucose is the holy grail of the world of biomedical diagnostics, and dehydration is a very useful parameter in the field of wellness, which is one of our main commercial aims,” bioengineer Zeev Zalevsky, of Israel’s Bar-Ilan University, said in an announcement. The researchers said a commercial device could reach market within two to three years.

The pulse tracker biometrics watch, under development by the Optics Research Group at the Delft University of Technology in the Netherlands, promises to deliver pulse data non-invasively and provide readings not impacted by a wearer’s movements, according to a second study.

“This paper shows for the first time that a speckle pattern generated from a flowing liquid can give us the pulsation properties of the flow in spite of motion-induced artifacts,” graduate student and biomedical engineer Mahsa Nemati said in the announcement. “Sophisticated optics is not necessary to implement this, so the costs for devices can be kept low. Another advantage is that the devices can be non-contact or far from the sample.”

The device news comes as wearable mHealth device interest is growing among consumers, grabbing interest from tech titans and drawing attention from federal agencies.

A survey from Mavosky Health/Kelton revealed that 81 percent of Americans would use a wearable health device. That presents a lucrative opportunity for tech companies looking to enter the industry, such as Microsoft, Google and Apple.

For more information:
– read the announcement
– check out the study on the glucose monitoring device
– here’s the study on the pulse tracking device

complex adaptive systems, data saving lives, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Cth Fund Country Comparisons

 

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

PPT: Exhibit_ES1_CthFund

Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Executive Summary

The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).

Expanding from the seven countries included in 2010, the 2014 edition includes data from 11 countries. It incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care. It includes information from the most recent three Commonwealth Fund international surveys of patients and primary care physicians about medical practices and views of their countries’ health systems (2011–2013). It also includes information on health care outcomes featured in The Commonwealth Fund’s most recent (2011) national health system scorecard, and from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD).

Overall health care rankingClick to download Powerpoint chart.

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage.5 Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes. The Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law. Thus, it is not surprising that the U.S. underperforms on measures of access and equity between populations with above- average and below-average incomes.

The U.S. also ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles. Other countries have led in the adoption of modern health information systems, but U.S. physicians and hospitals are catching up as they respond to significant financial incentives to adopt and make meaningful use of health information technology systems. Additional provisions in the Affordable Care Act will further encourage the efficient organization and delivery of health care, as well as investment in important preventive and population health measures.

For all countries, responses indicate room for improvement. Yet, the other 10 countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation’s substantial investment in health.

Major Findings

  • Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other 10 countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down. Continued adoption of health information technology should enhance the ability of U.S. physicians to identify, monitor, and coordinate care for their patients, particularly those with chronic conditions.
  • Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost. Patients in the U.S. have rapid access to specialized health care services; however, they are less likely to report rapid access to primary care than people in leading countries in the study. In other countries, like Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that trade-offs between universal coverage and timely access to specialized services are inevitable; however, the Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services.
  • Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing. Sicker survey respondents in the U.K. and France are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.
  • Equity: The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
  • Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

Summary and Implications

The U.S. ranks last of 11 nations overall. Findings in this report confirm many of those in the earlier four editions of Mirror, Mirror, with the U.S. still ranking last on indicators of efficiency, equity, and outcomes. The U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes. Switzerland, which was included for the first time in this edition, ranked second overall. In the subcategories, the U.S. ranks higher on preventive care, and is strong on waiting times for specialist care, but weak on access to needed services and ability to obtain prompt attention from primary care physicians. Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under the Affordable Care Act, low- to moderate-income families are now eligible for financial assistance in obtaining coverage. Meanwhile, the U.S. has significantly accelerated the adoption of health information technology following the enactment of the American Recovery and Reinvestment Act, and is beginning to close the gap with other countries that have led on adoption of health information technology. Significant incentives now encourage U.S. providers to utilize integrated medical records and information systems that are accessible to providers and patients. Those efforts will likely help clinicians deliver more effective and efficient care.

Many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, but the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, and with the enactment of health reform, the United States should be able to make significant strides in improving the delivery, coordination, and equity of the health care system in coming years.

us health care ranks last