Monday, March 31, 2014

Patients Come Second

Today is the deadline for the 2014 open enrollment under the Affordable Care Act, and there’s lots I could write about on that topic: the deadline suddenly getting softer, the frantic push for younger enrollees, the estimated $10b in subsidies that will be paid, or the surprising possibility that – after all the fuss and controversy -- we may hit the goal of 7m sign-ups after all, despite yet another glitch.  Then there’s the Hobby Lobby case currently before the Supreme Court.

But I’m not.  Instead, I want to talk about a couple of stories that got less attention and deserve more.  Both relate to patient safety.

The CDC reported that 4% of hospital patients – that’s one in every 25 – will get an infection due to their stay.  One in nine will die of that infection.  CDC thinks there is a trend towards improvement, but cautioned that earlier data on the topic isn’t directly comparable. 

It’s interesting to me that we apparently weren’t counting these indicators very carefully before, which doesn’t give me a whole lot of confidence about how well we’re counting them now.

CDC suggested that antibiotic-resistant pathogens played a large role in the infections.  In another report released earlier this month, they highlighted this problem, noting that physicians and hospitals vary widely – as much as three times -- in their use of antibiotics even for patients with similar conditions.  The President’s 2015 budget proposal calls for $30m to help the CDC detect outbreaks faster and improve collaboration across hospitals, among other proposals.  CDC estimates these measures could save 20,000 lives, prevent 150,000 hospitalizations, and save $2b. 

Seems like a good return on $30m.  We’re not doing this already?

We should remember that, for all that we spend on health care and for all our high-tech monitoring, estimates are that health care workers use proper hand washing as little as 30% of the time.  Antibiotic controls are all well and good, but seem sort of like chasing the horse after it is out of the barn.

In a commentary in JAMA Internal Medicine, physicians Scott Flanders and Sanjay Saint cite what they call the “chagrin factor” as an explanation for the antibiotic overuse, suggesting physicians don’t want to discover after the fact that they didn’t use an antibiotic when it might have been helpful for one of their patients.  They also noted that we have a tendency to place the interests of individual patients over broader societal interests (like minimizing antibiotic resistance), and recommend various measures that try to balance both interests.

What we should be chagrined about is the 4%, or about the 1 in 9, and certainly about the whole hand-washing thing.

Consumer Reports just released their own hospital safety ratings, showing wide variations in how hospitals perform on various safety measures.  They conclude that hospitals are not making safety a priority, as I’d touched upon in a previous post.  They also found that neither reputation nor teaching status necessarily made a difference in patient outcomes, which is consistent with a study by White, et. al. released earlier this year in Health Affairs.  Their study found that higher priced hospitals did better in reputation-based rankings like US News & World Report and not as well on more objective quality measures. 

The various studies illustrate that patient safety varies widely across providers, or that their ability to measure it does – or both.  Either way, it’s pretty scary.

The other patient safety news I wanted to bring up is a ballot initiative in California.  It seeks to raise the malpractice award limit of $250,000, which has been in place since 1975.  The proposal is being accompanied by a requirement to require random drug and alcohol tests for physicians, as well as to require physicians to use a prescription drug database to help combat patient abusers. 

Not surprisingly, the initiative is being opposed by the California Medical Association, which labels it the “trial attorneys’ ballot.”  They argue that it would only raise costs (although one would think that raising a cap after 39 years doesn’t seem unreasonable), and assert that the drug testing provisions have been added simply because they poll well among voters. 

They might well be right about the trial attorneys being behind the ballot, but what both sides should be thinking about is why the drug testing provisions do poll so well.  People who are supposed to care about patient safety should be working for those kinds of protections.  In fact, I wonder why physicians and other health care professionals don’t already face such drug tests everywhere already. 

After all, data suggests that 10-15% of physicians will have a substance abuse problem at some point in their lives.  The HHS Inspector General and a colleague raised this issue in an op-ed in The New York Times, Why Aren’t Doctors Drug Tested?  They cite cases where medical professionals with addiction problems stole drugs and adversely impacted patient care, but the problem is broader.  Over a year ago researchers from Johns Hopkins called for random drug and alcohol tests of physicians, as well as mandatory testing when there are unexpected patient outcomes – similar to what happens to pilots, railroad engineers or bus drivers when there are fatal crashes.  There hasn’t been a rush to put this into place.

On the other hand, states and some physician organizations, like the American Society of Interventional Pain Physicians, are in favor of allowing or even requiring physicians to have their patients take drug tests in order to get prescription painkillers.  Testing is OK for bus drivers and for patients, but not for physicians and other health care providers? 

Providers, heal thyselves.

Our health care system simply does not have a culture of patient safety, or of quality improvement, and the two are related.  Everyone is too focused on either increasing their own revenue or cutting someone else’s costs.  There’s precious little emphasis – well, financial emphasis anyway -- on team work, collecting and sharing data, or using the data to improve processes of care. 

Our malpractice system exacerbates the situation, as it focuses on placing blame rather than assuring quality.  As best I can tell, neither patients nor providers like the current system, nor benefit much from it.  The odds that a patient suffering harm from their care will actually get compensation, or that truly incompetent providers will be stopped from practicing, are better than playing the lottery, but not so much that you’d want to put a bet on it happening. 

If we’re truly committed to patient safety, it has to start with fuller, broader and better collection of data, then using that data to weed out the actually incompetent providers, to identify medical errors and substandard outcomes, and to create feedback mechanisms to improve patient care.   Studies have already shown that fuller disclosure of errors and even just apologies actually reduce both malpractice claims and possibly overall costs.  So why isn’t there more disclosure?

Recent studies have greatly increased estimates of deaths due to errors in hospitals and help expose the tip of the iceberg of errors in outpatient settings.  We know patient safety is a problem, and a big one at that.  It’s not sexy like ACOs or mobile apps, but if we don’t focus more of our attention – much more – on it then shame on us.

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