Stories from Slate Stories from Slate The Bounceback Problem <p> This year has not been a good one for rock singer and Poison frontman Bret Michaels. A lifelong diabetic, Michaels was admitted to the hospital in April for appendicitis. One week after being discharged, he returned with a massive headache caused by a brain hemorrhage. Again, not long after going home, he returned to the hospital with numbness on the left side of his body. He was diagnosed with a mini-stroke—perhaps from a blood clot that traveled from his leg, through a small hole in his heart, and up to his brain. It may seem improbable that someone could be in the hospital three times within 45 days for separate, serious health problems. But it isn't: Hospital bouncebacks are remarkably common.</p> <p>In medical jargon, a &quot;<a href="">bounceback</a>&quot; is a patient who returns to the hospital soon after being discharged. Reasons for bouncing back include problems like uncontrolled pain after a procedure, a surgical infection, or unexpected deterioration of the original reason for admission, such as heart failure. In Michaels' case, it seemed as if his three health problems were unrelated, but most readmissions are usually connected in some way. And this is why, even though reasons for bouncebacks vary widely, when a hospital has high bounceback rates, it is commonly considered to reflect poor medical care.</p> <p>What drives this concern over high bounceback rates? First, bouncebacks are massively expensive—a recent <a href=";keytype=ref&amp;siteid=nejm">study</a> of Medicare patients found that one in five admissions results in a bounceback within 30 days of discharge, costing the federal government an estimated $17.4 billion per year. Second, large differences in bounceback rates between <a href="">hospitals</a> can't be easily explained by differences in patients' underlying conditions, suggesting that at least some of these readmissions are probably avoidable. Finally, bouncebacks just <em>feel</em> wrong. Patients don't like to come back to the hospital, policymakers hate spending the extra money on a redo, and physicians are demoralized when confronted again with a patient they just released.</p> <p>But until recently, hospitals have never had a compelling reason to try to prevent bouncebacks. Hospitals are typically <a href="">paid</a> a flat sum for each inpatient stay—shorter stays equal higher profits. When patients bounce back, hospitals can charge the insurance company twice for the same patient with the same problem. Many hospitals also view bouncebacks as out of their control: If a patient boomerangs back because she doesn't follow doctor's orders, it's not the hospital's fault. </p> <p>Now, as policymakers target bouncebacks, things are changing. Hospitals must publicly <a href=";lat=39.9583587&amp;lng=-75.1953934&amp;stype=MEDICAL&amp;mcid=GRP_4&amp;stateSearched=PA&amp;measureCD=&amp;MTorAM=READM">report</a> their 30-day readmission rates for patients in whom the original reason for admission was heart failure, pneumonia, or a heart attack. Interestingly, it doesn't matter what the reason for the second admission was; it still counts as a demerit. And Obama's new budget rules will allow the Centers for Medicare and Medicaid Services—the group that doles out government health care dollars—to pay less to hospitals with higher relative readmission rates for these conditions starting in <a href="">2013</a>. </p> <p>These changes are not without controversy. Some observers point out that underlying conditions, not necessarily bad care, are what bring patients back to the hospitals they just left. In patients with chronic illnesses, like severe heart failure, it's frequently the case that no hospital stay could cure the problem. And a second admission could actually reflect better or more comprehensive patient care: A <a href="">report</a> &nbsp;published in the <em>New England Journal of Medicine</em> this month describes data from one hospital that had higher-than-average 30-day readmission rates but lower death rates for their patients with heart failure.</p> <p>It is also not entirely clear what hospitals should do to prevent bouncebacks. A frequently cited factor in high readmission rates is poor access to clinic doctors for follow-up. One <a href="">study</a> reported that in half of bouncebacks, the patient didn't have a scheduled doctor's appointment between the first and second hospitalizations. But several subsequent research studies have shed doubt on the assumption that getting people to their doctors' appointments after discharge will prevent bouncebacks. A recent <a href="">study</a> in the <em>Journal of the American Medical Association</em> found that hospitals with higher rates of follow-up appointments after discharge had lower bounceback rates, but the differences between the poor follow-up hospitals compared with the best follow-up hospitals were really minimal: 23 percent vs. 20 percent. A Mayo clinic <a href="">study</a> also found no correlation between follow-up appointments and subsequent bouncebacks. </p> <p>Another bounceback-prevention measure that jazzes policymakers is improved discharge planning—including clear instructions on changes in medications and doses, counseling on dietary restrictions (an essential part of preventing heart failure relapses), and careful explanations on how to identify worrisome symptoms. But there, too, the data aren't convincing: A recent <a href="">study</a> found that better planning is not strongly correlated with lower readmission rates.</p> <p>The lack of data supporting these two most promising bounceback-busters are troubling, given the potential for unintended consequences of punishing hospitals with high readmission rates. Patients at the highest risk for readmissions are those with the fewest personal resources—for instance, no cash and transportation to get to the pharmacy and fill expensive prescriptions. Hospitals that care for the poorest patients (many of whom have multiple medical conditions <em>and</em> no routine primary care) may be unfairly stung with penalties for higher readmission rates. Maybe worse, hospitals could attempt to game the system by enacting policies that keep readmissions at bay but are not good for patient care. For example, emergency physicians like us may be pressured to keep returning patients in the ER instead of admitting them to an inpatient unit where they would receive more comprehensive care.</p> <p>Nevertheless, quality and budget experts are pushing ahead in their <a href="">quest</a> to reduce readmissions. Despite the objections we've raised, we think this is probably for the best. These programs have already led to some fundamental improvements. Many hospitals are abandoning the belief that they can't do anything for the patient after he leaves the hospital. Some have hired <a href="">transition coaches</a> to work directly with patients and families to help them manage their post-hospital care. Hospitals and outpatient doctors have also started to collaborate around &quot;<a href=";filterByDID=0&amp;sortByDID=2&amp;sortOrder=descending&amp;itemID=CMS1204388&amp;intNumPerPage=30">episodes</a> of care,&quot; ensuring that the patient not only gets the right hospital care but also the right post-discharge care, in effect tearing down the silos that limit big-picture solutions. This type of outside-the-walls thinking is transformational for hospitals and is, at the highest level, a good thing. It's just unclear whether the best way to bring these changes is through financial penalties based around a less than perfect measure of hospital quality. </p> <p>Now, instead of a wheelchair ride to your car and a fist full of prescriptions, hospitals may be doing more to ensure a smooth, safe landing to keep you from coming right back. But open questions remain: Will these new incentives be enough for hospitals to invest in costly programs to keep patients healthy outside of the sliding glass doors? And, more importantly, will they be sustainable over the long term? </p> <p><em>Like&nbsp;</em> <a href=""><em><strong>Slate</strong></em></a><em><strong>&nbsp;</strong>on Facebook. Follow us on&nbsp;</em> <a href=""><em>Twitter</em></a><em>.</em></p> Fri, 30 Jul 2010 19:44:00 GMT Zachary Meisel Jesse Pines 2010-07-30T19:44:00Z Why patients can't stay out of hospitals. Health and Science Why patients can't stay out of hospitals. 2262319 Zachary Meisel Jesse Pines Medical Examiner false false false Why patients can't stay out of hospitals. Why patients can't stay out of hospitals. Patients often return to the hospital soon after being discharged High-Speed Care <p> We have all pulled aside on the road to let a speeding, blaring ambulance whiz by, assured by the collective wisdom that every second matters for the unlucky patient inside. But, in truth, there are tragic but opposing stories about the importance of speed during a medical emergency.</p> <p>Take the case of <a href="">Ashley Leveillee</a>, a seemingly healthy baby girl. On a summer day in 1996, just outside of Boston, Ashley had a seizure and turned blue in front of her horrified parents. It took 22 minutes for the ambulance to arrive. The medics, who took a circuitous route to the home, were observed (by police, who had arrived first) taking their time walking up the driveway. Then the ambulance crew struggled to get the baby anti-seizure medication she needed quickly. Ashley ended up paralyzed for life. Her parents received a $10 million settlement, in part because the medics &quot;took too long.&quot; The death of Princess Diana in 1997 is more famous example of too-slow emergency care. According to <a href="">reports</a>, Diana's ambulance ride to the hospital should have been five to 10 minutes but took 40 minutes because, applying standard French emergency procedures, they drove extremely slowly so as &quot;not to subject the fragile patient to shocks and bumps.&quot; American heart surgeon John Oschner <a href="">opined</a> that Diana may have been saved had she arrived at the hospital sooner. </p> <p>The <a href="">competing</a> story is about a woman who had only an injured finger when she died after her ambulance ran &quot;hot&quot;—lights and sirens blaring—through an intersection and crashed into another vehicle. And just recently in New York, two separate fatal ambulance crashes occurred while its medics were speeding to deliver care. The &quot;<a href="">Ambulance Crash Log</a>&quot; details many accidents in which <a href="">rescue vehicles require some rescuing</a>. </p> <p>Nothing represents the urgency of time in emergency care better than the blazing ambulance, its lights and sirens clearing its path. Some of the supposed importance of speed in medical emergencies is actually grounded in truth: For patients with <a href="">cardiac arrest</a>, the time it takes for someone to start CPR makes a big difference in survival. But for many other conditions, time (on the order of minutes) may not make as much of a difference as we once thought. </p> <p>Take the &quot;golden hour,&quot; a concept of emergency care that is so deeply held and widely disseminated that they named a British <a href="">TV show</a> after it. The theory of the golden hour proposes that patients with serious trauma who get to the hospital within 60 minutes of injury are far more likely to survive. On its face, this rule makes sense: If you are bleeding internally, a surgeon can stop the hemorrhage as long as she can get to the source of the bleeding quickly enough. While the golden hour <a href="">has become dogma</a>, it turns out not to be backed by good science. </p> <p>Now a recent <a href="">study</a> in the Annals of Emergency Medicine casts further doubt to the concept of the golden hour for patients with severe injury. The authors studied more than 3,000 trauma patients—those with low blood pressures from bleeding, head injuries, and difficulty breathing—and looked at various time intervals after a 9-1-1 call. The times were compared with outcomes for the patients in the hospital. The result: shorter intervals did not appear to improve survival. These results are fascinating, in part because the principal question—how important is speed in the care of trauma patients before they get to the hospital?—has never been so elegantly explored. Previous efforts to measure the effect of ambulance time on survival have been plagued by the fundamental problem that medics may behave differently, like driving faster or spending more time working on patients, depending on the severity of the condition, making it impossible to tease out the effect of time on survival. While some of these biases remain, the authors of this study used sophisticated <a href="">methods</a> to account for many of these problems, allowing the reader to reasonably conclude that for ambulance care, a few minutes either way neither saves nor costs lives for patients with severe trauma.</p> <p>What are the consequences of this new information? It may encourage some changes in the way ambulances behave on the roads. The <a href="">editors</a> of the journal that published the study proclaim, &quot;Routine lights-and-sirens transport for trauma patients … may not be warranted.&quot; This conclusion is driven, in part, by increased awareness of the <a href="">dangers</a> of speeding ambulances. Ambulance crashes occur relatively frequently, killing medics at a rate that is nearly <a href="">three times higher</a> than that of the average U.S. worker. In some places, three in four ambulance crashes <a href=";siteSection=1">occur</a> &nbsp;while the vehicles are running hot, even though lights and sirens don't <a href="">save</a> much time at all. More alarming are how bad the <a href="">injuries</a> are for people who aren't even in the ambulance, such as when drivers swerve out of their path to cause another crash or strike an unlucky pedestrian.</p> <p>But it would be wrong, and irresponsible, to claim that time doesn't make a difference in the delivery of emergency care. Some medical conditions are truly time-sensitive, such as episodes of choking, in which performing the Heimlich maneuver can be life-saving, and cardiac arrest, in which medics can shock and restart their heart. But as new and better evidence suggests that very small differences in time my not be as important as other factors in the delivery of care for seriously ill patients, we should be clear about policies that may save minutes but not lives. This is important, because many ambulance services are <a href=";jsessionid=6CAEFFACCC86A0E408D09857A8ADB966">benchmarked</a> for quality on response time, which in turn may encourage ambulances to continue to speed.</p> <p>Perhaps it's time to tell ambulance drivers to slow down and quiet down. Leadership organizations in prehospital care are on it: Reports such as <a href="">this</a> from the National Association of EMS Physicians speak to a need to negotiate the conflict for ambulances to get there quickly and get there safely. While we don't want more stories like Ashley's, we also don't want ambulance drivers putting themselves, their patients, and other citizens at risk, especially when minutes don't count as much as we once thought.</p> <p><em>Like&nbsp; <a href=""><strong>Slate</strong>&nbsp;on Facebook</a>. Follow us on&nbsp; <a href="">Twitter</a>.</em></p> Tue, 11 May 2010 17:07:00 GMT Zachary Meisel Jesse Pines 2010-05-11T17:07:00Z How fast should ambulances go? Health and Science How fast should ambulances go? 2253638 Zachary Meisel Jesse Pines Medical Examiner false false false How fast should ambulances go? How fast should ambulances go? Are speeding ambulances lifesavers or life hazards? Are Most Emergency Room Visits Really Unnecessary? <p> Much of the ongoing health care reform debate has focused on unnecessary health care expenses—specifically, medical bills that rack up without demonstrably improving peoples' health. According to Peter Orszag, the director of the federal Office of Management and Budget, about <a href="">$700 billion</a>, or 5 percent of the U.S. gross domestic product, is wasted on unnecessary care, such as extra costs related to medical errors, defensive medicine, and just plain fraud. At the center of this discussion are &quot;unnecessary&quot;<a href="">ER visits</a> for minor conditions—colds, headaches, and feverish <a href="">babies</a> —that could be handled more cheaply in doctors' offices. If we could only convince patients to take their stubbed toes to urgent-care clinics or <a href="">primary-care</a> offices instead of ERs, the thinking goes, we could save a load and help fix this whole health care fiasco.</p> <p>But there are a few problems with this logic. While the past decade has seen dramatic increases in the use of <a href="">emergency care</a> and ER <a href="">crowding</a>, ER care is but a tiny portion of the U.S. health care pie: less than <a href="">3 percent</a>. The claim that unnecessary visits are clogging the emergency care system is also untrue: Just 12 percent of ER visits are <a href="">not urgent</a>. People also tend to think ER visits cost far more than primary care, but even this is <a href=";ordinalpos=4">disputable</a>. In fact, the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors, as ERs are already open 24/7 to handle life-threatening emergencies. And while we're at it, let's dispel one other myth: Despite the belief that the <a href=";ordinalpos=3">uninsured</a> and undocumented flood ERs, most emergency room patients are insured U.S. citizens. </p> <p>Overall, our ERs are working about as they ought to be. <a></a> Dramatic news stories attempt to expose the problem of ER &quot;hyperusers,&quot; such as the tale of nine patients in Texas, eight of them drug users, who were responsible for a whopping <a href="">2,700 ER visits</a> in six years. <a href="">*</a> But ER abuse like this is the exception, not the rule. Most &quot;frequent flyers&quot;—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,<strong></strong>come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not.</p> <p>Of course, a certain number of ER visits can be labeled discretionary—care that won't make a patient live any longer or make him meaningfully healthier. While ER physicians do treat the critically ill and injured daily, much of their care relieves suffering, provides reassurance, and rules out serious conditions. But think about all the non-ER services that are also discretionary, such as many types of spine surgery (which may not have <a href="">lasting benefits</a>); cosmetic surgery (<a href="">nose jobs</a> are the ultimate discretionary health care expense); yearly invasive heart tests <a href="">doled out</a> in McAllen, Texas (but don't seem to make McAllen residents' hearts tick any better); and even some forms of cancer care, where &quot;good&quot; outcomes are counted if lives are extended by a few <a href="">weeks</a>. Non-ER discretionary care dwarfs the amount expended on &quot;unnecessary&quot; ER visits.</p> <p>In the end, most who go or are sent to the ER end up there for good reason. ERs are available for people on an immediate basis when primary care schedules are fully booked and doc-in-the-box CVS Minute Clinics don't have the resources to offer treatments beyond antibiotics and <a href="">earwax removal</a>. Economists who go looking through old records to find evidence of &quot;wasted ER care&quot; are going to discover some well-known pitfalls. Prudent layperson laws say that insurance companies can't deny payment when an ER patient worried he's having a heart attack ends up diagnosed with heartburn. </p> <p>In July 2007, then-President Bush exclaimed, &quot;I mean, people have access to health care in America. … After all, you just go to an emergency room.&quot; He was <a href="">lambasted</a> for this statement, but there may a kernel of truth to it. ERs are safety net for the United States and really do ensure that Americans always have someplace to go. Having an always-available resource to alleviate pain, make sure your baby is not truly ill, and patch you up after a nasty fall is vital, even if it turns out that your condition wasn't as serious as you feared. </p> <p>Ultimately, there's no reason to single out the ER as being more unnecessary than any other health care service. Saving health care dollars is about keeping people well and preventing the use of unnecessary medical procedures and tests, most of which are delivered outside the ER. What we should be doing is reducing unnecessary illness related to the culture of McDonald's, Marlboro, and Michelob by making sure people eat their veggies, take their blood pressure medication, and go for regular runs. Preventing people from getting sick will lower the use of emergency care—not by keeping the worried well from coming in but by avoiding the heart attacks and strokes in the first place.</p> <p><em><strong>Correction, <a></a> March 9, 2010: </strong>This article originally misstated the time frame of the nine Texas ER hyperusers' 2,700 visits. The visits took place&nbsp;over the course of six years, not one year. (<a href="">Return</a> &nbsp;to the corrected sentence.)</em></p> <p><em><em>Become a fan of&nbsp;</em> <a href=""><em><strong>Slate</strong>&nbsp;on Facebook</em></a><em>. Follow us on&nbsp;</em> <a href=""><em>Twitter</em></a><em>.</em></em></p> Tue, 09 Mar 2010 14:39:00 GMT Zachary Meisel Jesse Pines 2010-03-09T14:39:00Z Cracking down on ER use won't save us as much money as you think. Health and Science Are most emergency room visits really unnecessary? 2247051 Zachary Meisel Jesse Pines Medical Examiner false false false Are most emergency room visits really unnecessary? Are most emergency room visits really unnecessary? Do we need to crack down on unnecessary ER visits? Tax Breaks Under the Microscope <p>Last month, Senate finance committee Chairman Max Baucus, D-Mont., and ranking member Chuck Grassley, R-Iowa, released several <a href="">policy options</a> for health care reform. Buried on Page 31 of the <a href="">document</a> was a proposal to &quot;Modify the Requirements for Tax-Exempt Hospitals,&quot; which would require nonprofit hospitals to maintain minimal levels of charitable activity, limit aggressive collections, and restrict charges to the uninsured and indigent. The proposed penalties for noncompliance are severe: Hospitals that can't prove their &quot;community benefit&quot; will lose the tax benefits associated with nonprofit status.</p> <p> In the era of billion-dollar government bailouts to defunct corporations, why would the government target hospitals that supposedly serve the public good? The reason is big money. In fact, <a href="">$93.5 billion</a> in federal subsidies are provided every year in the form of tax breaks. But research shows that nonprofit hospitals behave no differently&nbsp;from for-profit ones. And in some cases, nonprofits have been caught mistreating the poor for the sake of financial gains. One example: A nonprofit academic hospital in Connecticut aggressively pursued &quot;deadbeat&quot; elderly patients by placing liens on their <a href="">homes</a>. More recently, several nonprofit Chicago <a href=",0,3128966.story">hospitals</a> were reportedly transferring uninsured patients to the county emergency room. Stories like this are what sets off <a href="">Grassley</a>.</p> <p>We think that the government should demand good behavior in exchange for tax benefits, but it is important to consider what may happen to patients if nonprofits find their tax breaks in jeopardy. This depends on how nonprofit hospitals respond. </p> <p>Ideally, the change would result in increased access for the uninsured, expanded emergency rooms so that those awaiting care won't <a href="">languish</a> on hallway stretchers and in packed waiting rooms, and a reconsideration of policies that <a href="">push out</a> the indigent and elderly in favor of those with more profitable diseases, like cancer and organ transplants. Because of the litmus test for charitable care, former &quot;undesirables&quot; would suddenly become desirable. Also, by discouraging aggressive collection practices, the uninsured wouldn't be further impoverished when they couldn't pay. But even these good changes could have a negative effect: longer waiting times for elective procedures as more E.R. cases eat up hospital beds. Lengthy delays for elective care are still the <a href="">norm</a> in the National Health Service in the United Kingdom, which places a high priority on E.R. <a href="">access</a>.</p> <p>A different response to the policy would be grimmer. Hospitals that believe stricter nonprofit rules would constrain their ability to compete may cut their losses and become for-profit specialty hospitals. By discontinuing the &quot;community benefit&quot; charade, they could choose to serve only those with good insurance and diseases that reimburse well. For-profit specialty hospitals don't have all-purpose E.R.s to service the community, nor do they maintain unprofitable services such as general medicine and psychiatry. This would clearly reduce access for many patients who need hospital services for serious but low-paying conditions: diabetic complications, congestive heart failure, pneumonia, severe schizophrenia. Driving nonprofit hospitals to become for-profit specialty hospitals probably won't improve the population's health.</p> <p>Hospital groups, which have <a href="">mobilized</a> to fight this new proposal, argue that rules mandating &quot;minimal levels of charitable care&quot; don't take into account the true community benefit of certain hospitals, including teaching, community services, and disproportionate care for patients with government insurance. However, the current proposal excludes certain institutions, including educational and research hospitals. The policy also comes at a bad time for hospitals, when many are seeing declines in revenue. <a></a> Some are on the brink of <a href=";title=health&amp;wpid=2057">closure</a>, like <a href="">Shriners Hospital for Children</a> in Greenville, S.C., which provides free care to kids. <a href="">*</a> Shriners is funded by an endowment, which took a hit in the recent stock market collapse and has seen a big decline in donations. In a down economy, increased taxes would make staying open even more difficult for nonprofits with already-thin operating budgets.</p> <p>Another question is how this policy will interact with additional changes that come along with health reform. Current efforts include plans to expand health insurance coverage to all Americans and reverse incentives that disproportionately reward sub-specialized, high-tech, and unproven care. How nonprofits could balance policy changes with a huge influx of newly insured patients is unclear.</p> <p>What is evident is the current system that incentivizes these hospitals to act like for-profit corporations needs reform. But it is important to consider that major changes in incentives can have unintended consequences. Government policies with the best intentions often do, like when the use of doctors' report cards for heart surgery patients resulted in a <a href="">worsening</a> of racial disparities in New York. </p> <p>New rules like those proposed by Baucus and Grassley will make it bad business for nonprofit hospitals to drop off uninsured patients on <a href=",0,3911487.story?coll=la-home-headlines">skid row</a>. But it's also uncertain whether incentivizing hospitals to go round them up will make health care any cheaper or outcomes any better.</p> <p><em><strong>Correction, <a></a> June 19, 2009: </strong>Due to an editing error, the article originally and incorrectly stated that a Shriners hospital in danger of closing is in Greenville, N.C. The hospital is in Greenville, S.C. (<a href="">Return</a> &nbsp;to the corrected sentence.)</em></p> Fri, 19 Jun 2009 11:05:00 GMT Zachary Meisel Jesse Pines 2009-06-19T11:05:00Z Should nonprofit hospitals be forced to stop behaving like greedy corporations? Health and Science Should nonprofit hospitals be forced to stop behaving like greedy corporations? 2220784 Zachary Meisel Jesse Pines Medical Examiner false false false Should nonprofit hospitals be forced to stop behaving like greedy corporations? Should nonprofit hospitals be forced to stop behaving like greedy corporations? Sens.&nbsp;Max Baucus (left) and&nbsp;Chuck Grassley Health Care Scare <p> A colonoscopy may be the routine medical test that people fear the most. But for more than 10,000 Veterans Affairs patients, the most alarming part came long after the test was complete. In February, they each received a letter saying <em>You received a colonoscopy with an instrument that may have been contaminated with hepatitis and/or HIV</em>. The letter confessed that those serpentine, fiber-optic cameras used to perform routine screening tests for colon cancer had been improperly sterilized in three hospitals in Florida, Georgia, and Tennessee for the past four years. Although we may never know how many patients <a href="">actually became infected</a> from the procedure, at last count, 38 patients tested positive for hepatitis or HIV after their colonoscopies.</p> <p>While upsetting, this story could be seen as just another preventable error in our dangerous health care system. In the past year, we have heard lots about medical mistakes: <a href="">Dennis Quaid's twins</a> and their blood thinner overdose at Cedars-Sinai. <a href="">Esmin Green</a>, who died from a blood clot while waiting for a bed in the E.R. Before that there was <a href=",8599,425201,00.html">Jessica Santillan</a>, the child who died from a mismatched lung transplant at Duke. Infected instruments aren't new news, either: Two patients died at Johns Hopkins in 2003 after being <a href="">exposed</a> to deadly bacteria in contaminated bronchoscopes, which are used to look into the lungs. </p> <p>Medical horror always makes headlines. But one of the biggest headlines of all was the 1999 Institute of Medicine report <a href=""><em>To Err Is Human</em></a>,<em></em>which announced that up to 98,000 preventable deaths occur each year in U.S. hospitals. Since then, health care improvement organizations such as <a href="">Leapfrog Group</a> have invested copious resources in reducing preventable errors. But a key issue has been overlooked in this movement: The original estimate—the 98,000 deaths—may have been way off. In fact, some of the researchers who conducted the original studies used in the IOM report <a href=";keytype2=tf_ipsecsha">re-evaluated</a> their data in 2002 and reported that had they used a different calculation method, the number of estimated deaths would have been less than 10 percent of the original. Oops. </p> <p>Another example of fuzzy math in patient-safety calculations: This <a href="">article</a> points to 5,000 preventable deaths per year in intensive care units. But other patient-safety researchers estimate that 53,000 <a href="">lives</a> could be saved annually by staffing intensive care units with only specialists. So how many ICU patients are really dying unnecessarily? Five thousand? Fifty thousand? It is hard to square these numbers, which are different by a whole order of magnitude. </p> <p>The problem is that it's really difficult to measure medical errors. Distinguishing avoidable injuries from expected complications is a particular challenge. Patients who are in the hospital getting high-quality care are often there precisely because they are quite sick. They sometimes get worse despite excellent care by the best nurses and doctors. And while some hospitals may be <a href=";browser=Firefox%7C3%7CMacOSX&amp;language=English&amp;defaultstatus=0&amp;pagelist=Home">better</a> than others, it turns out that monitoring medical mistakes can't differentiate the &quot;good&quot; ones from the &quot;bad.&quot; In fact, many of the items used by Leapfrog to measure patient safety—such as encouraging a &quot;<a href="">culture of safety</a>&quot; to promote an atmosphere in which staff members can discuss safety concerns freely or requiring hand-washing to prevent the spread of germs—have been shown to have <a href="">no real effect</a> on your chance of leaving the hospital alive. </p> <p>Because it's so tricky to calculate deaths and adverse reactions caused by medical errors, tabulating mistakes can't reliably define high-quality medical care. Clearer metrics include measures of care coordination, such as how long you wait before an appointment or to be seen in the <a href="">E.R.</a>, or whether care is in line with evidence-based guidelines. In this context, let's revisit the VA debacle. Believe it or not, the VA excels at delivering high-quality, well-coordinated, and evidence-based care, as documented by Dr. Philip Longman in his recent <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=0977825302">book</a> (the foreword was written by <strong><em>Slate</em></strong>'s Timothy Noah). But the VA's success doesn't make the contaminated colonoscope fiasco any easier in the (proverbial) end. </p> <p>A well-run hospital can still have system failures. In the case of the VA colonoscopies, the problem was unlikely due solely to incompetence. An <a href="">injury-control</a> or human-factors analysis, which we have written about on these <a href="">pages</a>, would likely find that either the scope or the sterilizing equipment was designed improperly. When it comes to medical errors, the best solutions don't focus on retraining or firing the workers who bungled the job. Instead, they come from initiatives to invest in equipment designed so that the mistake couldn't be made in the first place. In this case, the scope manufacturer claims that an <a href=";sid=1643842">auxiliary water tube</a> wasn't cleaned as instructed. The VA should demand a safety mechanism to make it difficult or impossible to use an unsterile scope. The same principle applies to the Quaid twins: The bottles should have been designed to make it hard, not <a href="">easy</a>, to give an adult dose of the medication. </p> <p>Ultimately, what's a patient to do when medical care is needed? When high-profile medical errors occur at the <em>U.S. News &amp; World Report</em> No. 1 <a href="">hospital</a> and cultures of safety don't save lives, it might be difficult to trust you'll leave the hospital healthier than when you arrived. The answer is to have realistic expectations and recognize that things are improving. (The fact that trusted journals and health care organizations report preventable death rates that may be overestimated by a factor of 10 should also be some small comfort.) Medical ranking systems are imperfect, but <a href="">strides are being made</a> &nbsp;to find better ways to differentiate high-quality care. Designing (and using) processes that make it hard to make mistakes through incremental change are a step in the right direction, even if individual safety initiatives don't change aggregate mortality rates. But you don't need big numbers to demand improvement. Whether 98,000 or 9,800 preventable deaths occur in hospitals each year, it is still way too many. </p> <p>And realize that dramatic medical numbers (even not entirely correct ones) can be a call to action that saves lives.</p> Wed, 03 Jun 2009 17:01:00 GMT Zachary Meisel Jesse Pines 2009-06-03T17:01:00Z How to avoid medical mistakes. Health and Science How to avoid medical mistakes. 2219535 Zachary Meisel Jesse Pines Medical Examiner false false false How to avoid medical mistakes. How to avoid medical mistakes. Can medical mistakes be avoided? Sniffle While You Work <p> In <a href=",_M.D."><em>Marcus Welby, M.D.</em></a>, the early-'70s medical version of <em>Leave It to Beaver</em>, hospitals were depicted as sterile environments with shiny equipment and starched bed sheets. More recent medical dramas have gotten dirty: <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=B00005JLFT"><em>E.R.</em></a>, <em> <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=B0009WPM1Q">House</a></em>, and <em> <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=B00005JO9J">Grey's Anatomy</a></em> are a lot more likely to feature episodes in which a patient is admitted with a broken leg and later gets infected by flesh-eating bacteria. While not all TV medicine reflects real life (it's not that common to call a <a href="">code black</a> in order to extract a ticking time bomb from a patient's abdomen), new studies are published every month on <a href="">hospital-acquired</a> infections. Not even celebs are immune: According to reports, <a href=",2933,491804,00.html">Michael Jackson</a> suffered serious infection after his most recent nose job.</p> <p>This raises an important question: Why do people get infected while <em>in</em> the hospital? The first and most obvious answer is that hospitalized patients are sick and vulnerable because their immunity is compromised. But hospitals are also dirty places that can (and do) serve you up a side of microbes along with that lukewarm bouillon. Hospitals house hordes of people with infections together in close quarters, and bugs are bound to spread. While some of this can be prevented through infection control, doctors frequently don't do a great job of washing their <a href="">hands</a> or their <a href="">stethoscopes</a> between patients. But there's another reason, which no one who works in a hospital likes to talk about: Doctors tend to show up to work sick.</p> <p>Now, why would a doctor dare come to work with a contagious disease and examine my grandmother with germy hands? </p> <p>Coming to work ill is part of the culture of medicine. A favorite saying on surgical wards is &quot;We're rounding with you, or we're rounding on you&quot;—if you're missing work, you better be so sick that you're admitted to the hospital. Sick doctors have been known to do rounds while dragging IV poles and receiving fluids for GI illness. Gross, but it happens. This culture of work-first/self-second may not be such a terrible thing: Patients want dedicated doctors who study hard and won't sleep unless their patients are tucked in. But this hard-nosed culture can cause problems, especially when overtired doctors make <a href="">mistakes</a> because a cold has stuffed up that same hard nose. </p> <p>In some hospitals, working while under the weather is basically policy. Some hospitals have been <a href="">reported</a> to fire workers who take too many sick days. Residents on a well-known hospital's internal medicine service are allotted two sick days per year. Any more than that, and they work an extra week. When a poor doc wakes up coughing and achy on what would be her third sick day, there's no real choice: She sucks it up and hobbles to work. One would hope that she would wash her hands more diligently that day, but there's still a good chance some hapless patient will catch whatever she's got. In all likelihood, the otherwise healthy M.D. will recover without a problem. But the newly infected patient, who was already sick, might not be so lucky.</p> <p>Hospitals may promote this culture in part because of the <a href="">limitations</a> on hours that residents can work.&nbsp;Unfortunately, the guidelines can make already tight schedules even more packed. When people call in sick, sometimes a healthy but sleepy member of the team has to come back to work, or a disgruntled doc gets called in from a much-needed vacation. Either way, the sick doc at home—sniffling and coughing through <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=B00125JPN0"><em>The Price Is Right</em></a>—feels bad because he just screwed over a colleague. The next time he comes down with something, he might try to tough it through his shift.</p> <p>This culture of working sick isn't limited to doctors and hospitals. Other high-intensity professionals are loath to miss a day. But a banker showing up sick to the stock exchange is far less worrisome than a doctor coming to the hospital with the flu, which can kill a patient who has a compromised immune system. Some would argue that coming to work sick is better than the alternative. When doctors don't show up, their patients must be cared for by others who may not know important details of their medical history, possibly leading to <a href="">medical errors</a>. But the same arguments were made when rules came down forcing doctors in training to work fewer hours: Despite less continuity of care, patients didn't <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">fare</a> any worse.</p> <p>In the end, it conjures images of <em>Snow White and the Seven Dwarves</em>: You might think you're getting Doc, but instead you get Sneezy, Sleepy, or even Dopey. </p> <p>What's the solution?&nbsp;The first thing we can do is change the culture. Calling in sick should not be seen as wimping out. Unfortunately, cultures—even toxic ones—are incredibly stubborn. Another possibility is to alter the rules: Build greater redundancy into the system so that the two-day-only sick rule is not needed. A reduction in resident work hours should be coupled with an increase in the number of residents or other staff (such as physician extenders who can fill in). Also, an on-call backup person should be required on all services.</p> <p>Another solution is to try to keep doctors healthy. Believe it or not, just 42 percent of health care workers got <a href="">vaccinated</a> during the 2005-06 flu season. Hospital staffers should be encouraged, if not <a href="">compelled</a>, to get their flu shots. </p> <p>Even better, how about a little consumer-driven pressure? Demand that your hospital report the flu vaccination rates for its staff. Ask your doctor when was the last time he washed that <a href="">dirty lab coat</a>. Make her clean her stethoscope before she touches you with it. And the next time you see your doctor sniffling and coughing, tell him to take those superbugs home.</p> Fri, 06 Mar 2009 12:56:00 GMT Zachary Meisel Jesse Pines 2009-03-06T12:56:00Z Why doctors go to work sick. Health and Science Why doctors go to work sick. 2212897 Zachary Meisel Jesse Pines Medical Examiner false false false Why doctors go to work sick. Why doctors go to work sick. Why don't doctors stay home when they are sick? Sicko-nomics <p> The condition of the U.S. economy can be described generously as bleak. But while unemployment is on the <a href=";sid=ah7iC.ZTIZ2Y&amp;refer=home">rise</a> and the Big Three automakers <a href=",0,2605514.story">struggle</a> to remain afloat, the business of making people well seems relatively insulated. While some discretionary health care sectors are <a href=",0,2121656.story">not</a> growing, such as <a href="">LASIK</a> eye procedures and plastic surgery that patients pay for out of pocket, most health care workers still have jobs and can afford the occasional $4 latte.</p> <p>But the health care industry is <a href="">no oasis</a>. The very problems that brought our country to its financial knees are still at work today in health care. It comes down to the disordered competition that exists in both the mortgage and health care industries. </p> <p>If you pick up your college econ textbook, you'll read all about <a href="">Adam Smith</a> and how competition is fundamentally good. When companies compete, it results in a better product for the consumer: McDonald's competes with Burger King to make a better, cheaper hamburger. Problem is, in both the old, defunct mortgage business and <em>current</em> health care industry, the &quot;<a href="">invisible hand</a>&quot; fails to produce low-cost, high-quality, sustainable products. </p> <p>In the mortgage industry, this competition failure produced the banking crisis. During the housing bubble, banks competed with one another to sell risky mortgages that had a high likelihood of default. Now, <a href="">entire neighborhoods</a> have been left nearly deserted because of waves of foreclosures. In health care, competition similarly fails to produce better community health. Instead of competing with one another for the best outcomes, providers compete for patients with the most profitable diseases. Hospital care for cancer and heart surgery makes more money than hospital care for diabetes, pneumonia, or mental health. While all these services get reimbursed, some bring in more cash than others—in effect, cancer care is like <a href="">gold</a> while diabetes is like silver. </p> <p>As a result, <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">form follows finance</a>: Gilded diseases get the best care while the silver diseases are given lesser priority. (Ever notice that hospitals have hardwood floors in some areas, like the cancer units, while general medicine gets linoleum?) Mining gold generally means doing high-volume elective procedures and state-of-the art care—the stuff patients think will make them better in a short period of time. Mining silver involves primary and preventive care, like managing blood pressure. Because it's less lucrative to mine silver, even patients with comprehensive insurance are made to wait for doctors' appointments and often get <a href="">bumped</a> to E.R.s for regular care. In <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=1591397782"><em>Redefining Health Care</em></a>,<em></em>economists Michael Porter and Elisabeth Teisberg detailed how this gold-mining scheme interferes with creating the best health outcomes because it devalues certain treatments and marginalizes patients with particular diseases. Improperly treated diabetes can be just as lethal as untreated cancer, but while hospitals roll out the red carpet for cancer patients, diabetics get the shaft. </p> <p>E.R. patients make <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">less money</a> for the hospital than elective admissions. Therefore, running an overcrowded E.R. is a passive form of <a href="">cherry-picking</a>: By restricting the influx of these second-tier patients, the hospital can focus on the gilded cases by preferentially reserving space for surgical and cancer patients at the expense of others who <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">suffer</a> &nbsp;for hours in E.R. hallways. This is perfectly legal and increases profits but does not produce a healthier overall community. The University of Chicago Hospital has taken gold-mining to the next level, according to <a href="">reports</a>: The Urban Health Initiative is designed to <em>actively</em> cherry-pick by shipping out &quot;routine cases&quot; (read: less profitable) from the E.R. to local community hospitals so they can reserve inpatient beds for more <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">complex patients</a> (read: more profitable). But there has been some push back by regulators: Government officials may actually <a href="">challenge</a> the hospital's &quot;nonprofit&quot; tax status. And, as of this month, <a href="">Massachusetts hospitals</a> will no longer be able to use ambulance diversion (which is also <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">profitable</a>) to divert E.R. cases to other facilities.</p> <p>And just as mortgage companies used adjustable-rate mortgages to convince homebuyers they could afford homes they couldn't, health care is rigged to promote overuse at the expense of the consumer. This overuse comes in two forms: the excessive testing and limitless treatments by doctors <em>and</em> the voracious demand for these services by patients. Many of the health care services that people want and doctors recommend really have no proven value—like the full-body CT scan that <a href="">Oprah</a> bought. The patient doesn't really bear the brunt of the cost for most health care services—the insurer does—but these practices inflate premiums for everyone. There's no downside for doctors who order unnecessary tests, and no one really watches what doctors prescribe unless they are handing out narcotics like Percocet or directly hurting people. Most doctors practice conscientiously and do what they think is in their patients' best interests, but the point is that the system encourages the delivery of as many services as possible. More <a href="">liver transplants</a> equal more money.</p> <p>Neither medical care nor mortgages are fundamentally bad. But there are too few checks in the system to prevent people from getting the equivalent of a crappy burger.</p> <p>How can health reformers learn from the mortgage industry? One solution is paying for health care outcomes instead of health care services. Under this system, if the doctor makes you better, he gets paid—otherwise, no dough. But reimbursing on outcomes is problematic because it is difficult to know who should have gotten better but didn't, and who would have gotten better even without treatment. Doctors who take harder cases would look like they were bad at their job and maybe get paid less, possibly creating incentives for refusing harder cases. </p> <p>Another concept is the <a href="">Federal Health Board</a> (touted in a new <a href=";tag=slatmaga-20&amp;link_code=as3&amp;camp=211189&amp;creative=373489&amp;creativeASIN=0312383010">book</a> by the incoming secretary of health and human services, Tom Daschle). This board would be similar to the Federal Reserve and make nonpartisan recommendations on which medical tests and treatments Americans should get (i.e., which will be reimbursed). But <a href="">critics</a> of his plan worry that many treatments that actually <em>do</em> work don't have a lot of science backing them up. While this government scrutiny on medical care would likely tamp down costs, it could also result in the <a href="">rationing</a> of services. </p> <p>Yet another proposed solution is the <a href="">medical home</a>, where primary-care providers would get special incentives to manage and coordinate chronically ill patients. When we get sick, it can be quite a challenge to navigate the system and manage the myriad specialists. The medical home might make the lives of the chronically ill easier and reduce system costs by preventing expensive hospitalizations.</p> <p>But, ultimately, what needs to happen is an overhaul of the structure of the system. Just as financial reform is needed to ensure that mortgage companies don't hand out loans to those who cannot afford them, health care reform should focus on aligning what patients demand (to be and feel healthier) with health care reimbursement. An ounce of prevention is a lot cheaper than a pound of cure. Healthy diet and exercise are better than getting a heart stent and spending a week in the hospital after a heart attack. We need to reform the health system now so taxpayers don't get saddled with another trillion-dollar bailout.</p> Tue, 27 Jan 2009 11:58:00 GMT Zachary Meisel Jesse Pines 2009-01-27T11:58:00Z Health care reformers should look to the banking collapse as a cautionary tale. Health and Science Health care reformers should look to the banking collapse as a cautionary tale. 2209602 Zachary Meisel Jesse Pines Medical Examiner false false false Health care reformers should look to the banking collapse as a cautionary tale. Health care reformers should look to the banking collapse as a cautionary tale. Health care workers Trend Spotting <p> This flu season, if your head starts aching, your nose gets clogged, and your body gets the chills, there's a decent chance you'll turn to the Internet before heading to the doctor. You won't be the only one. Last month, to harness the powers of our collective Web searching for a cure, Google <a href="">announced</a> a cool new system called <a href="">Flu Trends</a> that tracks outbreaks by monitoring when users type search terms such as &quot;flu symptoms,&quot; &quot;influenza,&quot; or &quot;the flu.&quot; Google's team even published its <a href="">findings</a> in the prestigious scientific journal <em>Nature</em>. They reported that Flu Trends tracks almost perfectly with data on influenzalike illnesses that the CDC obtains from doctors' offices. And as an added bonus, Flu Trends detects outbreaks up to <a href="">two weeks earlier</a>, when people are still sitting at home sneezing into their keyboards.</p> <p>&quot;Syndromic surveillance,&quot; or using data that track trends in patient symptoms, has been a hot topic since the Sept. 11, 2001, and the <a href="">anthrax</a> attacks. The initial thought behind the now <a href="">gazillions</a> of dollars dumped into syndromic surveillance was to use sensitive monitoring systems to identify clusters of E.R. and doctor visits by patients exhibiting worrisome symptoms, like fevers and rashes, and to create an early-warning system for bioterrorist attacks. But as researchers from the Rand Corp. <a href="">point out</a>, syndromic surveillance is not all that when it comes to detecting bioterrorism. Anthrax symptoms like fever and cough mimic the flu, making it tricky to differentiate an attack from an influenza outbreak. But what syndromic surveillance <em>is</em> good at is detecting trends in the flu itself. And Flu Trends, which is really a new type of syndromic surveillance, reportedly has benefits over other types of surveillance.</p> <p>Flu Trends is certainly better than <a href=""></a>, where users report their symptoms. When sick, people are more worried about getting better (and using Google to figure out how) than reporting symptoms to a random Web site. Flu Trends is similar to a system in which doctors' offices report data on patients with flu symptoms to the CDC, which <a href="">publishes the results</a> each week. But we don't how Flu Trends compares with other types of surveillance systems, such as data from <a href="">drugstores</a> (to track purchases of cold medicine), <a href="">telephone medical hot lines</a> (to monitor patients who call in with flulike symptoms before a doctors' visit), <a href="">school absences</a> (to know when kids are not showing up at school), <a href="">E.R.s </a> (to identify diagnoses of actual flulike illnesses), laboratory data (to confirm the infection and know the viral strain), and <a href="">hospital discharge data</a> (for information on severity of illness and intensive-care use). But Flu Trends has one clear benefit over these systems: They are costly to maintain, while Flu Trends can get similar data on the cheap.</p> <p>But sometimes you have to spend a little to get a little. The problem with Flu Trends is that it doesn't give detailed info on who is sick. Apart from knowing where their Internet connections are located, Flu Trends tells us nothing about the users. Other systems come with additional information, such as demographics (age, gender, etc.) and give more detailed information on where the sick people actually live. This &quot;<a href="">situational awareness</a>&quot; helps epidemiologists know how the disease is spreading in particular populations and regions.</p> <p>But if officials monitored only Flu Trends, it would be difficult to sort the signal from the noise—in addition to losing critical details on who is sick. Things besides an actual flu outbreak can cause people to search the Internet for flu information. We would imagine that Flu Trends would spike on the release date for a flu-related movie—maybe <em>Outbreak 2: Electric Booga-Flu</em>. And what happens if a pandemic flu scare hits the nightly news? Flu Trends' ability to detect when the real pandemic hits will be obliterated when people, including those without symptoms, start to search the Internet. Monitoring drugstore sales has the same issue: A jump in cold-medicine sales may mean a flu outbreak, but it could also mean that CVS is running a sale or that flu fear is causing people to stock their medicine cabinets.</p> <p>The real question here is: So what? Why is so important to predict a couple of days ahead of time which states have lots of people with flu symptoms? Some say this information may spark health officials or doctors to produce special news bulletins, intensify hand-washing campaigns and flu vaccination efforts, let hospitals know to up their staffing levels, or even prescribe preventive antiviral meds, like <a href=";utm_source=google&amp;utm_medium=cpc&amp;utm_content=Tamiflu%20-%20General&amp;utm_term=tamiflu">Tamiflu</a>, to high-risk people. Those sorts of prevention efforts do actually reduce the flu spread. But it is unclear what good a one-week heads-up can do when it is already clear that the flu is coming, anyway.</p> <p>If Flu Trends is not the perfect surveillance system, then what is? The ideal system would let health officials know where influenza hits, how serious it is, and what the viral strain is. It would give us advanced warning to help prevent spread. Problem is, no data source has all this info—each has limitations. The flu has a predictable pattern: You get infected, you spread it to your family and friends, you start feeling awful: fever, cough, aches, headache. Then you complain to your wife or mother (whom you have already probably infected), telephone a nurse hot line, or buy some cold medicine. Ideally, you call in sick to work or avoid school, and, finally, you type &quot;flu symptoms&quot; into your Google browser. There is surveillance for all these activities—except for the whining, of course. Most folks ride it out at home and stay in bed for a couple of days, but some go to doctors' offices or to the E.R, and some of those doctors will order influenza tests. But by the time we have the hospital data, the flu has not just arrived, but has infected lots of people, and interventions to reduce its spread are less effective.</p> <p>Probably the best answer is for officials to use multiple data sources for syndromic surveillance simultaneously and perform graded interventions with each new bit of information. When the earliest warning system goes off (like Flu Trends or drugstore purchases), health officials might announce &quot;Flu is here&quot; and urge people to get more rigorous with hand-washing and get vaccinated if they haven't already. Then, when the hospital data warn that the flu has landed in a particular location and is having an extreme effect on a population (like children or the elderly), targeted interventions can be implemented at the regional level, as with <a href=";keytype2=tf_ipsecsha">Tamiflu </a> prophylaxis, or even considered for more drastic measures, such as temporarily <a href=";nav=menu682_2_3_2">shutting</a> day care centers.</p> <p>Another future trend in syndromic surveillance is sharing information between jurisdictions that now adhere to political boundaries such as states, counties, and cities. Diseases often spread across state lines without asking permission from health officials. So <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum">regionalization</a> or nationalization (like <a href="">Biosense</a>) of surveillance may help us identify outbreaks that are not confined to one particular area.</p> <p>But despite all this, it is important to keep a grounded perspective. The way to prevent yourself from getting the flu is to get your shot, wash your hands, and stay away from coughing people. When you do get it, stay at home, for goodness' sake. And along with your daily searches for Britney Spears and government bailouts, keep on Googling for flu remedies. By doing so, you're not just informing yourself, you're also helping the health department. But no matter how accurate Flu Trends is, we can be certain about three things this winter: 1) Flu will come; 2) many people will get sick, and some will die from the infection; and 3) Google Flu Trends will prevent neither 1) nor 2).</p> Fri, 12 Dec 2008 12:15:00 GMT Zachary Meisel Jesse Pines 2008-12-12T12:15:00Z Even Google can't cure the flu. Health and Science Why Google Flu Trends is not the cure for the flu. 2206516 Zachary Meisel Jesse Pines Medical Examiner false false false Why Google Flu Trends is not the cure for the flu. Why Google Flu Trends is not the cure for the flu. VIP Syndrome <p>Not long after Sen. Edward M. Kennedy was diagnosed with <a href="">brain cancer</a> this summer, he summoned his very own group of national cancer experts, a &quot;<a href="">tumor board</a>,&quot; to discuss his case and recommend treatment. The <em>New York Times</em> called his health care &quot;<a href="">extraordinary</a>&quot; for several reasons: Tumor boards are usually convened by doctors for complicated cases, not by patients, and rarely is it possible to summon &quot;more than a dozen experts,&quot; as Kennedy did, on short notice. While it may not be surprising that someone with fame, stature, or wealth would receive more attention when ill, it seems unfair that he should get better medical care than the rest of us.</p> <p>Actually, he <a href="">doesn't</a>. Although the senator has unlimited access to expert doctors, he suffers from a different disease that rarely afflicts soccer moms but can be even deadlier than cancer: very important person syndrome. <a href="">VIP syndrome</a> strikes when doctors and nurses treat VIP patients differently—and, in the end, the medical care is worse, not better. Because VIPs are special, doctors and nurses deviate from usual protocols. As a result, the patient receives something other than the standard of care.</p> <p>Doctors act differently with VIPs because caring for celebrities is distracting. They know their decisions will be scrutinized not only by hospital administrators looking over their shoulders but also by the press and public. Doctors who would normally ask, &quot;What's the best care for a 76-year-old man with a malignant <a href="">glioma</a>?&quot; instead wonder, &quot;What do we do now that Senator Kennedy has a malignant glioma?&quot; The answer is sometimes different because of the tendency to overthink decisions and overemphasize treatments celebs think they need—even if those treatments are experimental and not necessarily the standard of care. </p> <p>VIP syndrome affects not only treatment but also testing decisions. If Joe the Plumber requests a CT scan he doesn't need, doctors simply say, &quot;No, Mr. Plumber.&quot; But Joe Biden can get any CT he wants. Some health care <a href="">programs</a> for corporate executives even involve routine full-body CT scans as screening tests as part of the &quot;chairman's physical.&quot; The problem is that these expensive and detailed tests may actually increase the risk of cancer from <a href="">radiation exposure</a> and have never really been shown to improve anyone's health. And if there is an incidental finding, as there often is, more tests might be ordered, which may lead to unnecessary biopsies. And doctors perform heroic procedures on VIPs not just when there is <em>clear</em> benefit but when there is <em>any</em> question of benefit. After Harvard doctors recommended that Kennedy not have brain surgery, the doctors at Duke <a href=";oref=slogin&amp;oref=slogin">overrode</a> that decision in favor of removing the tumor. Another problem: When procedures are performed, the most senior guy does it. The senior guy is not necessarily the most skilled at doing the procedure—because he has been busy being an academic chairperson and is out of practice. </p> <p>So, who gets VIP syndrome? It can strike anyone who is clearly famous or important, like a Kennedy, a Baldwin brother, a big hospital donor, or the superrich. And much like other diseases, VIP syndrome can be contagious: Relatives of famous people can easily catch it. (Kennedy's <a href=";_r=2">family members</a> also had their own tumor boards.) VIPs even have their own special hospital floors. While these units have better nurse-to-patient ratios, fluffier pillows, and concierge service, the nurses are not specialized. For example, a VIP with a broken hip may not get the nurse who usually takes care of orthopedic patients. And many VIP wings are located far away from the rest of the hospital. One prestigious academic hospital has a VIP section with oak-paneled rooms and high-thread-count bed sheets, but among medical students and residents, it's known as &quot;Marberia,&quot; a conflation of its real name and Siberia, because of its remote location. As a result, VIPs may get seen last in the morning because doctors have to trek to different buildings on rounds. And if a VIP has a true emergency, like a cardiac arrest, in the comfy unit, doctors may be dangerously far away.</p> <p>VIP syndrome is compounded when the patient is in critical condition. After President Ronald Reagan was <a href="">shot</a>, the doctors couldn't hear one another <a href="">because</a> so many people were shouting at the same time. Imagine trying to make a good medical decision or communicate when the E.R. is teeming with administrators, Secret Service agents, and gawking hospital staffers not involved with the case. Even when doctors have the time to think clearly, they still make mistakes when dealing with celebrities: Former President Gerald Ford was <a href="">discharged</a> from the hospital with the diagnosis of an inner-ear infection when, in fact, he had suffered a stroke. </p> <p>As we have both encountered as practicing emergency physicians, some VIPs travel to the hospital toting their own doctors. While a trained advocate can be helpful, it can sometimes interfere with medical decision making and lead to diagnostic delays and mistakes. In this <a href="">story </a> from the <em>Boston Globe</em>, when a VIP came into the E.R. complaining of chest pain from swallowing a large pill, the &quot;boutique bedside bodyguard&quot; insisted on an immediate echocardiogram, a heart test rarely performed in the E.R. VIPs also have issues with privacy because everyone is interested in their health. In 2007, after super-VIP George Clooney was in a motorcycle wreck, 27 hospital employees were investigated for <a href="">inappropriately peeking</a> at his X-rays and leaking his test results to the media. VIP privacy is a common problem: UCLA Medical Center workers have <a href="">snooped into</a> the medical records of Britney Spears, Farrah Fawcett, and Maria Shriver.</p> <p>Since most of us are not VIPs, why should we care? Because VIP syndrome can affect you, too, especially if you're in the same hospital—the VIP will get her MRI first, so you may have to wait a little longer. But if you don't happen to be waiting for the same MRI scanner, you can benefit from an ill VIP. When a celebrity comes down with your disease, the illness can suddenly become more important: VIPs sometimes start foundations when they get sick—like <a href="">Michael J. Fox</a> did with Parkinson's disease.</p> <p>But the truth is that most VIPs, especially the very famous ones, actually want to be treated as regular patients. In addition to having to deal with clicking cameras and googly-eyed autograph-seekers, VIPs probably know that fame can also mean star-struck doctors and nurses. So, what can wary VIPs do to make sure that they don't get VIP syndrome? Alas, not much. Even when the VIP checks in under an assumed name, going incognito in a hospital can be next to impossible. Trust us. Sunglasses might help them avoid paparazzi on the street, but a thin hospital gown doesn't do the same trick. Word spreads quickly among nosy hospital staff.</p> <p>Though doctors don't always do right by their prominent patients, VIPs do have ultimate access. And for anyone who has tried to navigate the U.S. health care system, access to doctors is paramount. VIPs don't wait for appointments, they don't get <a href="">bounced</a> to the E.R. for routine care, nor do they get <a href="">boarded</a> on E.R. hallway stretchers for 12 hours. But access and attention don't always translate into better outcomes, especially if the care team doesn't follow protocols. The truth is that there is probably a happy medium: If you are Joe Six-Pack, it may help to be mistaken for a VIP because you won't have to wait weeks for a doctor's appointment. But if you are a candidate for vice president, you'd be better off if hospital staff thought you were just a hockey mom.</p> Thu, 30 Oct 2008 10:26:00 GMT Zachary Meisel Jesse Pines 2008-10-30T10:26:00Z Why the rich and powerful might get substandard medical care. Health and Science Why the rich and powerful might get substandard medical care. 2203331 Zachary Meisel Jesse Pines Medical Examiner false false false Why the rich and powerful might get substandard medical care. Why the rich and powerful might get substandard medical care. The Allure of the One-Stop Shop <p> Perhaps you've heard about the guy who is wrecking the American health care system. He is uninsured, has no major medical problems, and loves the emergency room. He is said to stroll in about once a month to various E.R.s around town for reasons as diverse as a simple cold or an STD check. He usually asks a doctor to excuse him from work and complains if he doesn't get a prescription for narcotic pain medication. The cost of his medical care is unnecessarily high because for his complaints, the E.R. is more expensive than a doctor's office would be. But our legendary visitor doesn't have a primary-care doctor: Why should he, since everything he needs is at the local E.R.?</p> <p>If you believe the <a href="">conventional wisdom</a>, the E.R. abusers of our nation are especially responsible for many problems in health care. They fill up E.R. waiting rooms and because they can't (or won't) pay their medical bills, the insured patients who prudently wait for weekday appointments to see their doctors end up bearing the costs of the abusers' in the form of higher insurance premiums. The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States.</p> <p>The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. E.R. use by the uninsured is <a href="">not</a> wrecking health care. In fact, the uninsured don't even <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">use</a> the E.R. any more often than those with insurance do. And now, a new <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">study</a> shows that the increased use of the E.R. over the past decade (119 million U.S. <a href="">visits</a> in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office. So, the real question is: Why is everybody, insured <em>and</em> uninsured, coming to the E.R. in droves? The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care.</p> <p>Asymmetric information is one of the reasons for excess E.R. use—information that doctors have but patients don't. The truth is, many people don't have a good way to judge whether a headache or fever is a true medical emergency. Heralded medical stories may contribute: Think about the coverage about <a href="">Tim Russert's sudden death</a> from a heart attack right after receiving a clean bill of health from his cardiologist. Now say you're the one feeling lightheaded: How do you know you're not going to just drop dead? All the health information on the Internet can serve only to feed the flames of misunderstanding and worry: Google any symptom, and you find a comprehensive list of the deadly diseases that you may have but probably don't. It's quite nerve-racking, and it drives people who may not need to be there to the E.R.</p> <p>The way that care in outpatient clinics is <a href=";jsessionid=L8KhshV2xTpr9Rm04GwxYJznnz1j1p0WFCRYV3tkRq48yDFGc04k!-711215224!181195629!8091!-1">organized</a> and reimbursed also sends people to the E.R. when what they really need is to see or talk to their primary-care doctors. Here the problem is that primary-care providers have little reason to tell someone <em>not</em> to seek E.R. care, especially if the complaint is potentially serious and may take a little bit of effort to sort out. Assume a patient calls his doctor about a new symptom. Ideally, after listening on the phone and deciding that it's probably nothing serious, the doctor arranges an office visit for the next day, offers reassurance, and averts an unnecessary late-night E.R. visit. But doctors don't get reimbursed for that call. And what if they tell a patient to wait and something bad happens? Then malpractice lawyers have a field day. </p> <p>Either way, this scenario assumes that a patient can get through to his doctor. Many come to the E.R. because it's always open. We thank the many doctors who do talk to their patients (even though they don't get paid) and schedule the urgent appointments that keep their patients out of our E.R.s. But they may be more the exception than the rule. The old adage &quot;Take two aspirin and call me in the morning&quot; has been replaced by an office secretary or voice-mail message that says, &quot;Hang up and call 911 or go to the nearest E.R.&quot; </p> <p>What about those <a href="">long E.R. waits</a> when patients get there—aren't they a disincentive for going unless you're sure you're having a real emergency? Yes, E.R. crowding has been shown to lower <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">patient care</a> and <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">satisfaction</a>. And yet, patients may still rationally decide that the E.R. is more efficient than waiting for a doctor's appointment, waiting more for outpatient lab and radiology tests, and then waiting again for another appointment to review and discuss the results. In 2005, the <a href="">EMPATH study</a>, a national survey of emergency-department patients, sought to answer why patients choose the E.R. rather than other sources of care. The authors found that nearly all such patients believed they had a real emergency. They also cited an appreciation for quality and convenience. Over the past 30 years, E.R.s have insisted on the availability of rapid test results and highly trained personnel. The EMPATH study suggests that patients with nonemergency cases may also now seek the high-tech, high-quality E.R. care just because it's there. This affects how doctors use the system, too: sending patients to the E.R. when they have a new symptom, need a CT scan, or should see a specialist. E.R.s have become one-stop shops, assuming that you're willing to lie on a foam stretcher in a hallway for eight hours. </p> <p>Low co-pays push patients in the same direction. The <a href="">RAND Health Insurance Experiment</a> in the 1970s showed that patients use more health care (even if it doesn't make them healthier) when they don't bear much of the cost directly. In the E.R., a single $100 co-pay may feel like a relative bargain compared with the alternative: fees for multiple trips to the doctor and testing centers, hours on the phone arranging the whole process, and days of missed work. </p> <p>If you are uninsured, it's even more rational to get your care in the E.R. Federal <a href="">law</a> requires a screening exam and treatment for any patient who shows up, regardless of whether they can pay. And hospitals, after a string of negative press <a href="">reports</a>, are less likely than ever to aggressively <a href="">pursue</a> patients for delinquent medical bills. In contrast to ERs, primary-care clinics <a href="">routinely</a> fail to provide urgent appointments for patients who are uninsured, even if they have a serious condition or are willing to pay cash for their visit.</p> <p>The problem, of course, is that societal health costs end up higher because of E.R. overuse. This is because many conditions can be <a href="">prevented</a> through health maintenance programs, like managing blood pressure or cholesterol, which E.R. doctors don't do. Instead of the relatively small costs of seeing the doctor and taking a generic blood pressure pill, we foot the bill for expensive, high-tech services when the uninsured with no preventive care develop strokes and heart attacks.</p> <p>Ultimately, it doesn't take a genius to outline a cure for E.R. overuse. We could start by changing the incentives to line up with rapid access to urgent primary and specialist care. This could be achieved by developing reportable standards for acceptable waiting times for appointments. Next time you call the dermatologist and they say, &quot;We'll see you next summer,&quot; you could cry foul. We also should restructure the payment system for primary-care doctors so they won't go belly up if their schedules aren't 100 percent booked, given how little they're paid per patient. They should get paid for those after-hours calls. Then there are fixes on the E.R. side: Some emergency rooms have considered taking <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus">steps</a> to try to change the law on medical screening exams and triage, so that some E.R. patients could legally be sent away without seeing a doctor as long as they could get to see a primary-care doctor within 24 hours. Another promising <a href="">idea</a> is to send patients with nonemergency conditions directly to affiliated primary-care clinics without a complete E.R. work-up. But this would only work if clinics made room for E.R. patients, who may or may not have insurance. </p> <p>For now, if you're stuck in the E.R. with a real emergency (like chest pain that you think might be a heart attack) and you sit down next to a guy with a clearly minor problem (like a sprained pinky), just remember that he may be making as rational a choice as you are. The problem is a lot bigger than his aching pinky and the pain in your chest.</p> Fri, 12 Sep 2008 11:06:00 GMT Zachary Meisel Jesse Pines 2008-09-12T11:06:00Z The real reasons why people go to&nbsp;the E.R. when they shouldn't. Health and Science Why people overuse the E.R. 2199645 Zachary Meisel Jesse Pines Medical Examiner false false false Why people overuse the E.R. Why people overuse the E.R. Emergency rooms are crowded with patients who don't need to be there Waiting Doom <p> Last month, Esmin Green, a 49-year-old mother of six, <a href="">tumbled off her chair</a> and onto the floor of the Kings County psychiatric E.R. waiting room in New York City. Members of the hospital staff saw her lying there but did nothing for about an hour. When Green was finally brought into the E.R., she was dead. An autopsy revealed that she died from a <a href="">pulmonary embolism</a>, which occurs when a blood clot forms in the leg, breaks off, and travels to one or both lungs. This can also kill long-haul airplane passengers who sit in one spot for hours: The blood sits stagnant in their legs for so long that it clots. You could say that Green, too, had been on a plane ride of sorts. She'd waited for a psychiatric-unit bed to open up for more than 24 hours, roughly the same time as a trip from New York to Tanzania.</p> <p>The surveillance <a href="">video of Green collapsing</a> and lying untended, as hospital staff at Kings County fail to respond to her collapse, is inexcusable by any stretch. And so <a href="">Nancy Grace</a>, for one, focused on the negligence. But what's largely missing from this story is the likely cause of Green's pulmonary embolism. The answer lies in a far more systematic and widespread danger in hospital care: E.R. waits. Why was Green sitting and waiting while blood pooled in her legs? Despite increasing <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">evidence</a> that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in <a href=";amp;Cmd=Search&amp;amp;Term=Wilper%20AP%5BAuthor%5D&amp;amp;itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus">E.R. wait times</a> over the past few years, even for those who are the sickest. </p> <p>A major cause for E.R. crowding is the hospital practice of <a href=";source=MI&amp;sp=12032790&amp;sid=0/N/245257/1.html">boarding inpatients</a> in emergency departments. This happens when patients who come to the E.R. need to be admitted overnight. If there are no inpatient beds in the hospital (or no extra inpatient nurses on duty that day) then the patient stays in the E.R. long past the completion of the initial emergency work. This is what happened to Green, and <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">it has become widespread and common</a>. The problem is that boarding shifts E.R. resources away from the new patients in the waiting room. While E.R. patients wait for inpatient beds, new patients wait longer to see a doctor. As more new patients come, the waits grow. And an E.R. filled with boarding patients and a full waiting room is an unhappy E.R.: The atmosphere is at once static and chaotic. If you or a loved one has waited for hours in an E.R., you know what we mean. The environment can be unsafe and even deadly. A recent <a href=";itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum">study</a> found that critically ill patients who board for more than six hours in the E.R. are 4 percent more likely to die.</p> <p>What hospital would promote such a practice? Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients. Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money.</p> <p>In effect, then, E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor. E.R.s are safety nets: By law, we who work in them see any and all patients, regardless of their ability to pay. But as more E.R. beds are devoted to boarders, the E.R. has less space for new patients, which keeps a lid on the number of un- and underinsured. So unless you are having a heart attack and can jump the line, your emergency—though it may still be serious—may wait for so long that you give up and go home. Bad for you, good for the hospital's bottom line. E.R. boarding also tamps down nursing costs, again not to your benefit. Hospitals generally maintain strict patient-to-nurse ratios for inpatients. But many hospitals don't apply the same rules to the E.R. because they can't control the number of patients who come in that way. Sometimes the nursing ratio in the E.R. can be as high as 8-to-1. That's unacceptable in inpatient units, but just stack 'em in the E.R. hallways and suddenly it's OK.</p> <p>What about the staff upstairs, who take care of the admitted patients once they leave the E.R.? Their incentives are misaligned, too. Put yourself in an inpatient nurse's shoes. You are overworked, and your current patients need attention. You get a call from the E.R., saying that a patient like Green is ready to come upstairs. The bed is clean and ready. But you have 20 more things to do before your shift ends in two hours, and you won't get paid an extra cent if you accept Green to the empty bed. Can't she wait just a bit more in the E.R.? When the next nurse comes on fresh, you tell yourself, she can admit the new patient. You won't get in trouble for stalling because no one really measures how long patients stay in the E.R.. So you tell the E.R. nurse that the bed isn't ready yet. This practice of &quot;<a href="">bed-hiding</a>&quot; is more common than you think.</p> <p>What can be done about all this? We think the answer is that hospitals should have to disclose and take responsibility for how long E.R. patients—that is, <em>you—</em>wait for beds. But, not surprisingly, hospitals have lobbied hard to not be <a href=""> held accountable for E.R. crowding and boarding</a>. If they won't measure and eliminate E.R. boarding on their own, then the federal <a href="">Centers for Medicare &amp; Medicaid Services</a>, which pays many hospital patients' bills, or <a href="">the Joint Commission</a>, which accredits hospitals, should take this on. </p> <p>And let's also hold congressional hearings on E.R. boarding. In England, the National Health System now has a rule that 98 percent of patients have to spend less than <a href="">four hours in the E.R.</a>. Apparently, the son of a member of parliament spent too long in an E.R., we've heard. Esmin Green wasn't well-connected. But her death should serve as a similar prompt to fix the problem of endless waiting.</p> <p>Meanwhile, if you have to go the E.R., you can vote with your feet. When you are really sick, of course, go to the closest E.R. or call an ambulance. But if you can wait long enough to choose, go to the E.R. where they don't make patients wait or board for long periods. Yes, we know—since hospitals don't publicize E.R. waits or boarding, you'll have to go by word of mouth. If, despite your efforts, you or your grandmother is forced to lie in the E.R. all night, complain directly to the hospital administrators who actually have the power to fix the problem. But don't count on any major changes. As long as hospitals profit more from boarding and aren't forced to admit to doing it, your trip to the E.R. will be as long as a flight to Africa—but without the in-flight movie and far more risky.</p> Thu, 24 Jul 2008 10:54:00 GMT Zachary Meisel Jesse Pines 2008-07-24T10:54:00Z How hospitals are killing E.R. patients. Health and Science How hospitals are killing E.R. patients. 2195851 Zachary Meisel Jesse Pines Medical Examiner false false false How hospitals are killing E.R. patients. How hospitals are killing E.R. patients. Video of Esmin Green, who died in an E.R. waiting room