Patient Safety Blog

It is instructive and interesting to read about Senator Edward Kennedy's treatment for his brain tumor.

The linked article describes the change in direction between May 20th of this year, when Kennedy's brain cancer was first disclosed and surgery was not discussed as a possible treatment, and two weeks later, when neurosurgeons performed a "successful" surgery on his brain.

Why the change? From the article:

Precisely why Mr. Kennedy’s treatment course changed is not known; he and his doctors are not talking to reporters.

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

As the article notes, Senator Kennedy called similar conferences of experts when one of his children was diagnosed with bone cancer and the other with lung cancer. He has been known to advise his colleagues in the Senate to use this method when dealing with an illness in the family.

Obviously, powerful senators can do things the rest of us cannot. Again, from the article:

Mr. Kennedy can tap leading doctors for answers in a way few patients could. His celebrity status aside, he has spent a career promoting insurance and other ways to improve the health of Americans. And he has had a track record of being thorough and diligent in researching medical options when relatives or friends have fallen ill.

Nevertheless, despite Kennedy's power and influence, there are ways in which the average person can imitate his example and seek second and third opinions on their medical care:

Several doctors not connected with Mr. Kennedy’s case said in interviews that they admired his resourcefulness in getting more opinions simultaneously. At the same time, these doctors said many average patients gained competent advice, without a command performance, by sending pertinent records to experts for their opinions.

Many patients search the Internet for medical information and ask that their scans and other data be sent electronically or by overnight services.

Then such patients visit, call or write the consultant.

The potential negative consequence of all this opinion-shopping is that people may focus on what they want to hear and disregard everything else. This is partly why the doctors quoted in the article strongly recommend actually meeting physicians whose advise you intend to take (rather than just sending records and receiving written responses). That way the physician can make sure your expectations are realistic and address your specific concerns.

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Posted In: Accessibility of Healthcare , Cancer , Communication , Disclosure , Doctor-Patient Relationship , General , Surgery

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Tara Parker-Pope recently had an article on how fewer and fewer patients trust their doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

What are the reasons for this new distrust? Several factors appear to be involved:

(1) Patients often don't understand what is going on with their health care because doctors and nurses are too rushed to explain things to them. Dr. Sandeep Jauhar, cardiologist and author of Intern: A Doctor's Initiation, is quoted in the article with a story of a patient who was transferred from one hospital to another with no explanation for why. He blamed a "broken system" for such failures to communicate.

(2) There has been greater coverage in the news of medical error, the power of the drug industry and the flaws in health care administration.

(3) The Internet makes information much more available, so patients can be informed skeptics. Drug companies also market directly to patients, so they come into the doctor's office with their own desires and opinions on what medications they should take. The upside to this is that patients have the information to challenge a doctor's errors. The downside is that many end up taking a drug commercial, for instance, at face value and will not listen to a doctor's reservations about the efficacy of a drug.

Again, from the article:

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

The whole article is worth reading. In addition, the article's page also has an embedded video clip of interviews with people discussing their attitudes to their doctors.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Disclosure , Doctor-Patient Relationship , General , Medications , Standard of Care--Hospitals , Testing

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In our previous post, we discussed Dr. Peter Bach's comments on Medicare funding for unnecessary (in his opinion) testing. In response to Bach's article on the subject, the NY Times published readers' letters, most of which were highly critical of Bach's proposals about Medicare and testing.

The first letter, from Dr. Brant S. Miller, is especially interesting because Miller argues that Bach's proposals are nothing new:

We already tried capitation with H.M.O.’s in the 1990s, and that turned out to be a disaster. The media reported countless abuses by H.M.O.’s that killed or maimed patients as the insurers paid doctors more for denying care and less for providing care. Fee for service turned into plea for service. So, here we go again.

Since the 1990s, patients have been told that your doctor is greedy and doing unnecessary tests. And by the way, you shouldn’t have to pay much out of pocket, and there shouldn’t be any forms to fill out. Meanwhile, Tim Russert dropped dead when a one-minute CT scan could have shown progression of disease in his left anterior descending coronary artery.

Another interesting letter is from professor of neurology Michael Hutchinson. Hutchinson criticizes Bach for making "sweeping statements" and corrects his portrayal of the facts regarding testing and equipment use:

In fact, an extensive study done by doctors at Massachusetts General Hospital on physician ownership of imaging equipment was published last year. The study failed to define a major increase in imaging by doctors who own their equipment compared with doctors who do not.

Perhaps this has to do with strict government regulation, but imaging costs have actually been declining in the last two years. The total cost of M.R.I. scanning is now a fraction of 1 percent of health care.

Hutchinson also points out that imaging leads to fewer hospital and emergency room visits and also fewer procedures done, which helps reduce health care costs overall.

Those two letters were intriguing, but all of the letters responding to Bach are worth perusing.

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Posted In: Testing

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Peter Bach, former adviser to the Medicare and Medicaid administrator, wrote a NY Times op-ed arguing that the Medicare system pays doctors for how many tests they run with a given piece of equipment but not for how much time they spend with patients. Readers responded with letters on the subject.

From the op-ed:

Medicare pays doctors for specific services. If a patient has a checkup that includes an X-ray, a urine analysis and a physical, Medicare pays the doctor three separate fees.

Each fee is meant to reimburse the doctor for the time and skill he or she devotes to the patient. But it is also supposed to pay for overhead, and this is where the problem begins. To Medicare, a doctor’s overhead (or “practice expense”) includes such items as rent, staff salaries and the cost of high-tech medical equipment. When the agency pays a fee to a doctor who has performed a CT scan, it is meant to cover some of the cost of buying or leasing the scanner itself. Services using more expensive equipment generate higher fees.

Any first-year business school student can see the profit opportunity here. The cost of a CT scanner is fixed, but a doctor earns fees each time it is used. This means that a scanner becomes highly profitable as soon as it’s paid for.

In contrast, the doctor-patient visit, which involves no expensive equipment, offers no significant profit opportunity. So the best way for a doctor to make money in his practice is not to spend time with patients but to use equipment as much as possible. That means moving the maximum number of patients through the practice, and spending the minimum amount of time with each one.

Bach offers suggestions for how the system should be reformed. He also includes evidence showing the increase of testing.

The informed patient on Medicare should ask questions about exactly what tests are being performed and why, and should not be concerned with taking up too much of the doctor's time.

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Posted In: Testing

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The Washington Post has a thorough and informative article on HealthCentral Network, an online start-up based in Arlington that gives curious readers information on health issues and forums where they can discuss ailments with others.

The site also has a system where visitors can find doctors or patients blogging about their illnesses. The owners of HealthCentral hope that providing a platform for this kind of independent research, communication and socialization will prove to be a good business proposition. They believe it will set them apart from other online health sites. Their hope is that, as more and more readers with health questions use their sites, drug companies will flock to advertise on HealthCentral's pages.

The Washington Post article is worth reading for its descriptions of and quotations from HealthCentral's visitors, which give insight into why people find this type of website useful.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Self-care

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Starting October 1, 2008, Medicare will no longer pay for eight hospital-acquired conditions that could be prevented if hospitals followed the proper guidelines.

Those eight conditions are bed sores, objects left inside the patient during surgery, falls that occur when the patient is in the hospital, blood incompatibility, air embolism, mediastinitis (infection of the area between the lungs, which can happen after a heart bypass surgery), catheter-associated urinary tract infections, and certain bloodstream infections. In addition, several other conditions have been proposed as additions to the list.

The purpose of this change is to provide an incentive for hospitals and health care providers to avoid errors and prevent neglect of patients. If both Medicare and the patient refuse to pay for treatment of a hospital-acquired condition, then the hospital is stuck with the costs, and most hospitals would obviously wish to avoid that.

This is a long-overdue incentive for hospitals to reduce the incidence of these events which should never happen.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: General , Medical Error , Standard of Care--Hospitals , Surgery

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A Spanish study, conducted on 250 participants of varied nationalities, shows that 24% of pregnant women feel poorly informed by their gynecologists and that nearly half do not take any pre-natal course.

Considering the medical, social and emotional importance of pregnancy and childbirth, it is especially vital for pregnant patients to be informed and in control of their health care during gestation and birth.

From the article:

The Head of the Obstetrics and Gynaecology Department at the Hospital Clínico San Carlos, Miguel Ángel Herráiz, who presented the results of the survey...explained that the aim of the study is to find out pregnant women's preferences during birth, with there currently being a tendency in administrations and the media in favour of a more natural birth. With regard to the high number of women who believe their gynaecologist does not inform them properly, the expert recognises that "we need to provide a birth plan and explain well and at all times how the process is going to be".

The survey asked about questions that have become more pressing in recent years, such as whether or not Cesarean sections and other medical interventions ought to be done as commonly as they are at present.

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Posted In: Gynecology

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The American Red Cross collects and gives out about 43 percent of the blood given to medical patients in this country, which is why it may be unnerving to learn that the organization has not been following federal quality-control standards.

From the article:

The F.D.A. found shortcomings in the way the Red Cross screens donors for possible exposure to infectious diseases, failures to swab arms properly before inserting needles, failures to test for syphilis and failures to discard potentially risky blood, among other deficiencies.

There is no evidence of actual harm resulting from the Red Cross's failure to abide by federal standards. However, the reason for this lack of evidence is partly because Red Cross has failed to investigate potential harm. If nobody looks for evidence of harm, then naturally it will not be found.

Again, from the article (which should be read in its entirety):

All told, the Red Cross failed to investigate more than 130 cases of suspected post-transfusion hepatitis between 2000 and mid-2002.

Often the problem is bureaucratic. Just this week, the F.D.A. chided the Red Cross for distributing more than 200 blood products that the organization itself had identified as problematic but failed to intercept before distribution. Other times the failure is deliberate. A blood facility in Philadelphia, with approval from a senior national executive, decided not to recall some 600 units of blood that had been collected using improper methods.

What can a patient do to limit the possibility of receiving improper blood? Very little. In an emergency situation, there may not be any time to inquire closely into the origins of a blood donation. However, the Red Cross is taking steps to ameliorate its problems by re-vamping its blood donation services and creating a centralized database to track the blood.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Transplants

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Officials with the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) say that the all types of fresh tomato associated with the recent salmonella warnings are now safe to eat.

From the article:

The FDA had been gradually clearing tomato-growing regions in the United States and Mexico since it issued the warning June 7. As the weeks passed, however, growers argued the warning was becoming moot because it was no longer possible for areas that were harvesting in April to still be producing tomatoes.

Criticism of the tomato warning intensified as people continued to get sick. Investigators began looking at other potential suspects and turned their attention to cilantro and jalapeño and serrano peppers.

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Posted In: Product Safety

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Tara Parker-Pope discusses a New England Journal of Medicine study that compared a Mediterranean diet, an Atkins diet and a diet with about thirty percent fat based on American Heart Association Guidelines.

The study had obese participants, who lost (on average) only 6 to 10 pounds over two years. From the article:

The biggest weight loss happened in the first five months of the diet — low-fat and Mediterranean dieters lost about 10 pounds, and low-carbohydrate dieters lost 14 pounds.

By the end of two years, all the dieters had regained some, but not all, of the lost weight. The low-fat dieters showed a net loss of six pounds, and the Mediterranean and low-carbohydrate dieters both lost about 10 pounds.

Researchers said the results sound modest, but they said the small weight loss had resulted in improvements in cholesterol and other health markers.

The obvious lesson to take from this study is that diets are not very effective when it comes to significant weight loss, but have good consequences for health overall. A focus on weight loss may lead people to ignore other important elements of health. The whole article is worth reading, as the study has many nuances.

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Posted In: General

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Unsurprisingly, there are wide global disparities in survival rates of cancer patients. This is partly because of the relative wealth of different countries. However, there are huge disparities within the United States as well:

In the United States, the lowest survival rates are in New York City, except for rectal cancer in women, where Wyoming scores worse. The best survival rate for cancer in the United States is in Hawaii, the researchers found.

Idaho also has a high survival rate for rectal cancer, and Seattle has the highest survival rate for prostate cancer.

But, there's a big disparity in cancer survival rates between whites and blacks in the United States, and it favors whites. The differences range from 7 percent for prostate cancer to 14 percent for breast cancer. This disparity is most likely due to differences in the stage of cancer when it is diagnosed, the researchers said.

We have discussed the impact of race and region on health care quality before on this blog. Unfortunately, not everyone can count on getting the appropriate kind of service from their health care providers depending on their circumstances, as this new study re-affirms.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Cancer , General , Insurance

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Senior citizens who bring company to their doctor or hospital visits receive better medical care, according to a new study published in the Archives of Internal Medicine. Of the 38.6% of elderly patients who brought a companion along on their medical visits, the most common person to bring along was a spouse or an adult child, followed by other relatives and friends and neighbors.

The effects of bringing along a companion are clear and beneficial:

The parts that these companions played varied. Primarily, they aided communication in the visit, with 63.8% of companions filling this role. Of these, 44.1% reported recording physician comments and instructions, 41.5% communicating information related to the patient's medical conditions to a health professional, 41% asking questions, 29.7% explaining the instructions given by the physician, and 3.3% who translated the English language. Companions filled other roles as well, with 28.4% of all companions present for moral support and to provide company, 16.6% to help schedule appointments, and 8.4% to provide physical assistance.

Additionally, the elderly patients who regularly brought companions were more satisfied with their physicians' services, including technical skills, information dissemination, and interpersonal skills. If their companions actively assisted with communications, the patients rated their physicians' informational and interpersonal skills more highly. This trend became stronger in patients who reported themselves to be in worse health.

Not only is an elderly person more likely to feel better during the visit if he or she brings along a supportive person, but it will also lead to better communication with the doctor.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Disclosure , Standard of Care--Hospitals

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Laura Landro, in her column "The Informed Patient," discusses the problem of adults neglecting to get vaccinated for new illnesses. Not only that, but adults forget or are unaware that some childhood vaccinations lose efficacy after some time and need to be re-done. Skipping pre-travel vaccinations is also a common error.

Part of the problem is insurance: not only is vaccination for the very young more likely to be encouraged, but it is also more likely to be covered by insurance providers.

The whole column is worth a read, but here are some disturbing statistics Landro cites:

-only 2.1% of adults are vaccinated for tetanus, diphtheria and whooping cough, despite the existence of a combination vaccine for all three.

-only 1.9% of adults have been vaccinated for shingles. The shingles vaccine is recommended for all adults over 60.

-only 10% of women from 18 to 26 have received the vaccine for human papillomavirus, which can lead to cervical cancer, and which most insurance providers will cover.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Cancer , Infections , Medical Error , Medications , Vaccinations

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The NY Times has a long and informative article on the pressures physicians face to give patients with heart problems unnecessary CT angiogram scans, which are very expensive and not demonstrably more effective than cheaper tests.

Aside from the expense, the scans come with radiation exposure equal to as much as 1,000 chest X-rays.

Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, said Dr. David J. Brenner, director of the Center for Radiological Research at Columbia University. Younger patients and women are at higher risk.

Many patients do find it emotionally reassuring to get the results of these tests, since the CT scan allows the patient and doctor to actually see if the heart has any problems. However, perhaps part of the love of these tests stems from what Johns Hopkins professor of medicine Bruce Leff calls (in a letter to the NY Times editor) "gizmo idolatry":

As a geriatrician and health services researcher, I believe that the demand for cardiac CT scans is a textbook example of gizmo idolatry, or the implicit conviction that a more technological approach is intrinsically better than one that is less technological.

The other letters are worth reading as well.

Despite concerns about the efficacy of these tests, many doctors and patients swear by them and they will probably remain popular. As the article notes, Medicare decided to fund these CT scans despite lack of clear evidence of their usefulness, and private insurers will most likely follow suit.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Cancer , Testing

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Many people have a tendency to underestimate the devastating effects of diabetes, as Tara Parker-Pope points out in her recent NY Times article. She cites studies where participants ranked various diseases, giving diabetes only 4s and 5s on a scale of 1 to 10 (10 being the worst).

Several factors give people this optimistic view of diabetes: lack of direct fatalities, knowledge that people live seemingly normal lives with the disease, and knowledge that the disease is manageable with medications.

But as Parker-Pope notes, this view is erroneous:

But diabetes is anything but minor. It wreaks havoc on the entire body, affecting everything from hearing and vision to sexual function, mental health and sleep. It is the leading cause of blindness, amputations and kidney failure, and it can triple the risk for heart attack and stroke.

“It is a disease that does have the ability to eat you alive,” said Dr. John B. Buse, a professor at the University of North Carolina School of Medicine who is the diabetes association’s president for medicine and science. “It can be just awful — it’s almost unimaginable how bad it can be.”

This is particularly true for people who lack the time or income for proper self-care. The "treatable" nature of diabetes generally applies only to those who have access to regular medical care. Even people with health insurance sometimes find the required standard of care too costly.

Diabetes is also associated with a wide range of other health problems, as the article lists, from liver disease to depression to hearing loss.

In short, nobody should be underestimating the effects of this disease.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Diabetes

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