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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