Archive for April, 2013
Making a diagnosis is difficult. And, doctors sometimes get it wrong. “Wrong” is often harmless, usually expensive, and sometimes deadly.
An article about incorrect diagnosis appeared this month in the British Medical Journal Quality and Safety which has been widely reported, including by the Wall Street Journal. Dr. Tehrani and his co-authors correlated health insurance claims (diagnosis) with malpractice suits. They found “diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.”
One might think the errors happen because the underlying problem is very rare. On the contrary, the bulk of errors happen with common conditions.
Another article this month in JAMA Internal Medicine by Dr. Singh and co-workers reported on common types of diagnostic errors — many of which were common in primary care: (italics are blog examples)
- no chest x-ray for cough and high fever
- no chest x-ray for cough and high fever
- Decompensated congestive heart failure
- no BNpeptide checked
- Acute renal failure
- no check of basic metabolic panel for fatigue
- ignoring Mammogram findings or blood in sputum
- Urinary tract infections
- not checking urinalysis or treating soon enough
The flaw in the process that contributed to the wrong diagnosis included:
- Inadequate patient encounter (too short or not focused on problem)
- Not seeking referral when needed (like not getting a cardiology consult for chest pain)
- Patient related factors (not returning for follow-up)
- Not taking risk factors into account (like family history of colon cancer)
- Losing track of test results (urinalysis report filed but not viewed)
- Not getting the right test (not getting a chest x-ray for shortness of breath)
Problems at the time of patient encounter are a major contributor:
- Poor history taking (provider did not listen or ask questions)
- Inadequate examination (provider did not examine problem area — like a breast nodule)
- Inadequate testing (not considering a colonoscopy for blood in the stool)
When a person has a health problem the whole idea is to connect the dots …problem…diagnosis…treatment. If the diagnosis is not correct then good treatment is disconnected.
Providers often do not consider enough possible causes for abnormal findings. Those possibilities are called the “differential diagnosis”. There are books and several free sites on the Internet that provide such lists. One such site is DiagnosisPro. If you like other sites leave a comment please. Some electronic record applications include a differential diagnosis automatically — nice feature which should always be installed.
So, what is the solution? Most experts agree, the quality of the provider-patient interaction must improve. Providers need to follow known guidelines plus use differential diagnosis aids. Patients need to look out for themselves by using the Internet or books to understand symptoms and test results. The best solution is a stronger partnership between patients and providers. See earlier posts in this blog about shared decision-making and patient centered care.
Can all errors be prevented? NO. To err is human. The point is to minimize the errors, and there is obviously a lot of room for improvement.
Payment of health care providers by volume of service (fee-for service) rather than quality of service is blamed by many as the cause of high cost and low quality in the US health care system.
A possible solution was proposed in 2006 as the Accountable Care Organization (ACO). The concept is modeled after other advanced countries which have lower cost and higher quality health care than the US. The idea is to pay a large organization (the ACO) to provide all the care needed for a large group of people. In other words, a per capita system, with payments not related to volume of services.
Medicare and the Affordable Care Act are betting on ACOs. The private sector is moving that way as well. The following graph shows the number of ACOs in the United States (CMS data)
The following graph shows the increase in the number of ACOs starting in 2009 and ending the first quarter of 2012.
The insurance industry is so entrenched it is hard to think outside of terms like deductible, out of pocket cost, and premiums. And, current ACOs indeed use those terms. But, under the hood, the ACO is run with a budget based on the cost to take care of a person for a year.
So, perhaps sometime in the near future you will just purchase health care by the year — something based on your age and ranging between $100 and $400 per person per month. Undoubtedly, there will still be some co-payments in order to avoid over use of services by some people.
A well formed ACO has a strong focus on a medical home and should include pharmacy service (not Walmart,Target or Walgreens etc.), hospital service (not every hospital), doctors, nurses, physician assistants, x-ray services, medical equipment, and devices. Not every hospital in the ACO would duplicate services — some would have specialty expertise, like brain surgery or heart surgery.
The materials to run the ACO would be purchased in bulk. The providers would be predominantly on salary and the hospitals under a strict budget with mandatory quality levels for all.
The rise of ACOs is encouraging but the actual number of covered patients is not large and the internal payment for ACO providers is still rooted in volume of services. But, with time and pressure (mostly from the business community) ACOs should begin to lower costs to levels enjoyed by other countries.
Congress could speed the process to be ready for the aging baby-boomers. But, action in Washington seems nearly impossible. It seems hard to argue against lower cost and higher quality, but they will.
Patient NON-CENTERED care is a physician looking at a computer rather than the patient, not letting the patient have a minute to express what they are concerned about or not making follow up appointments for diabetes. Patient centered care is better care.
The International Alliance of Patients’ Organizations (IAPO) has listed the “Five Principles” of patient centered care. The list includes:
- Choice and empowerment
- Patient involvement in health policy
- Access and support
Four cultural phenomena are at the root of the patient-centered movement.
- Doctors are not always right and communicate poorly.
- One third of US citizens are illiterate about health issues.
- The Internet has exposed items 1 and 2.
- People are wary of the government changing the healthcare system
The slippery slope for many patients starts when doctors tell patients what to do, patients don’t know enough to ask questions, treatment is given , advice is not followed and the outcome is not what the patient wanted.
Patient-centered care may be the solution. Focus on the provider-patient interaction, improve provider-patient communication, educate the patient about the problems at hand, and let the patient have a larger say in their own health care.
There is a political side to patient-centered care which is the battle between the public good and the patient’s wishes. There is plenty of work to be done at the point of interaction between the provider and the patient. Worry over fluoride in the water, organic vegetables and workplace dangers are different topics, important, but not patient-centered care.
The insinuation fee-for-service medicine is somehow more patient-centered than other health-care systems is not logical. No matter what health care system is in place the notions of good communication, patient education and patient autonomy remain critically important.
Patients will suffer the consequences of their decisions. So, providers should never agree to bad medical care. The purpose of patient-centered care is not to “give the patient what they want”. But, rather to listen to the voice of the patient, communicate the best evidence-based guidelines and be a partner with the patient to make good decisions.
What is Shared Decision Making (SDM)? It is a process for patients to make good decisions about tests, medications, surgeries and just about anything health care providers might suggest. What it is, and what it is not — some examples:
A patient has frequent headaches and has a visit with a provider.
Scenario 1: The provider says “a CT scan of the brain is needed, so get that done and come back for a follow-up visit.” (Old school, doctor knows best)
Scenario 2: The patient wonders if a CT scan of the brain would be a good idea to make sure there is no brain tumor. The provider says “sure, the nurse will schedule it tomorrow.” (Consumerism, do what the patient wants)
Scenario 3: The provider says “there are a number of options including a trial of migraine medications or getting a CT of the brain.” Then the provider gives the patient a handout that lists independent sources for additional information. And, says “I will call you on Monday, after you have had a chance to review the information so we can decide what to do” (Shared Decision Making)
Group Health Cooperative in Washington State has made a big push to support SDM. The Group has made information available on the Internet to assist the patient for many common situations. 91% of patients who used the system found it “very important” or “extremely important”. Click to see an Example of shared decision-making by Group Health Cooperative.
Pros and Cons:
- The process takes longer than just doing what the provider says
- Usually the SDM comes to a decision the patient will support, so they will follow instructions and treatments more than an average patient.
- As long as the information reviewed by the patient is based on evidence based guidelines (well researched advice) then good decisions are possible. And, usually the decisions are less invasive and less costly.
When a headline reports a doctor did something bad at a hospital don’t you wonder what happened behind the scenes? What was the doctor doing and what was the reaction of people at the hospital?
Case in point: Michael Booth of the Denver Post reported on 4/11/13 about the disciplinary procedure against a local general surgeon. According to the report the surgeon was a frequent user of robotic surgery. But, things were not going well in the operating room.
2008 to 2010 the surgeon had several major complications including perforating the aorta while doing kidney surgery and leaving instruments and sponges inside patients. After at least 14 such incidents the hospital suspended him for 3 months.
He went back into practice but a formal complaint was registered April 2013 by the Colorado State Medical Board. Centura Health – Porter Adventist Hospital declined to provide details of the case citing the Colorado law protecting peer review activities from disclosure.
Were there warning signs? The CMS Hospital Compare website shows Porter Hospital has about average quality among Colorado hospitals. The Health Grades website entry for the surgeon is fairly unremarkable — no patient comments and no listing of disciplinary action. Clearly, these sources are not good for early warning.
Usual or unusual? The course of these events seems typical for a surgeon with quality problems in the hospital setting. Although typical, these events causes agony in the hospital quality department. The hospital board (mostly non-medical people) is involved and they are always horrified.
Cost to the hospital — a lot. The cost to the hospital in terms of staff to investigate the surgeon, due process, legal counsel, physician (peer) review, and extensive documentation is likely at least a half million dollars.
Money down the drain. All the hospital actions motor upstream against the current of revenue generated for the hospital by the surgeon. In other words, it’s really hard to barbecue a cash cow.
Is the hospital hiding something? One might wonder why the hospital peer-review process is protected (kept secret). The answer is very simple, if there was no protection then no quality review would ever be done. Lawyers are sometimes accused of chasing ambulances to get clients — no hospital quality review could be done with hungry lawyers reading every word.
The trip-wire. The main concern in this situation, and many others like it, is the extremely slow detection and subsequent resolution of the problem. The hospital department of surgery is on the front line for spotting surgeons with quality problems. If that department does not have a strong warning system then years can go by without other surgeons realizing bad things are happening. Sherlock Holmes would be using his magnifying glass on that department.
The nurse knows. Operating room nurses often know about a surgeon’s problems. But, saying something is like reporting on your boss — not so easy.
An eye in the OR. One simple way to check a surgeon’s technique is to video record surgery (it is especially easy to do this with robotic surgery) — then if questionable cases come to light the record can be viewed. Surgeons hate the idea of being recorded, again due to the legal implications should such a recording land in court.
Not over yet. It take several years before all the suits and Medical Board actions are settled.
The point: When you read something about a hospital taking action against a physician it is just the tip of the iceberg. The quality problem took time to find, took time to research, took time to try (unsuccessfully) to correct, and finally took time to take disciplinary action. Once the last step is taken the hospital tries to stay out of the news with the hope the trouble will not rub off on them. The hope is often dashed once the state investigates the actions of the hospital. Hindsight is 20/20, the typical state investigation concludes the final action should have been taken on day one.
The graph is based on 2009 data from the Centers for Medicare and Medicaid Services and displays the spending in dollars per person. There is a spread of costs from state to state. Key drivers for any state include spending for hospital care, prescription drugs and physician services. Utah has the lowest spending with outstanding performance in all three areas. Utah has an advantage of few smokers, few drinkers and few obese people. The explanation in other states is not so clear. States next to each other like Georgia and Florida have extremes of spending levels not easily explained on demographics. Florida has high spending like the Northeast probably representing a migration of both doctors and patients with a culture of high cost services. One would think Utah demonstrates the best efforts of US healthcare with favorable demographics. But consider other countries.
In the light of other countries Utah should probably be more like Sweden that has spending of $3722 per person. The public spending alone in the US should be achieving good health care for everybody but sadly that is not the case. Our overall health-care spending is so much higher than other countries it makes the state to state comparisons seem less important. But, the US needs a goal. So, lets take a shot at the goal: every state should have a goal of $6000 per person like Colorado. Well, Congress — get to work!
Laura Landro of the Wall Street Journal wrote an article “The Talking Cure” which appeared today (4/9/13). She makes several good points: 1) 39% of patients feel doctors communicate poorly, 2) better communication improves health and reduces cost and 3) there are ways to help doctors communicate more effectively.
These points are difficult for doctors to accept, especially the 39%. Yet, the data is undeniable; the oracle of Wall Street speaks truth. Although, most physicians do not like to hear such comments from the lay media the message has been communicated well and with empathy.
Many years ago the Iowa Health System had doctors at one clinic participate in a communication study. The patients were told that at the end of the clinic visit they would be given a test about what was wrong with them and what instructions they should follow. A ton of bricks fell on the clinic. The patients all had a pencil and paper and they would not let the doctors leave the exam room until the they had the answers to the impending quiz. After all, the patients did not want the doctor to look bad. The doctors tell the story of the experiment with fond memories and a feeling of gratitude for the lesson in communication. The patients did pass their tests!
The Wall Street Journal article comments on the “4 habits” of good communication for health care providers: 1) create rapport 2) elicit patient views (and listen), 3) demonstrate empathy, and 4) assess patient ability to follow a treatment regimen. It takes a lot of practice to think about the evidence-based practice-guidelines and simultaneously do those 4 things.
Doctors in training generally find video recording of patient interactions both stressful and time consuming. Video-based training takes time away from the operating room and clinic — but is that bad? College communication majors become very comfortable with video training — they see themselves in the video recording and they use the sessions to hone communication skills. Perhaps physician training programs should take a lesson from the department of communications.
Medical knowledge is a package within a wrapper. That wrapper is communication skill which may be as important as the package itself.
The above graph is from the Dartmouth Atlas of Health Care and shows the Medicare expenditure per patient for medical equipment in each state. As with most Dartmouth graphs, the point is to highlight tremendous variability across the country. The rules of payment are the same across the country yet the system fails to follow the rules. Consistency means reliability, but the opposite is also true, inconsistency means unreliablilty. Medical equipment includes such things as nebulizers, wheelchairs and walkers to name a few.
Sadly, the medical equipment business is a hotbed of fraud and incompetence. There are just as many elderly people per capita in Iowa as Florida, but Florida has no grip on costs. Arizona monitors Medicare equipment spending quite well, but Texas is out to lunch.
There are so many problems it is hard to know where to start, here are a few examples:
- The rules for equipment are incomprehensible (just look at the CMS web site for proof) so States have difficulty following the rules and crooks can easily submit fraudulent claims.
- Wheelchairs are essential for quality of life for many people. But, for many elderly people who have other people push them around the much less expensive “transport chair” is sufficient.
- Compressor/nebulizer equipment for asthma and COPD is 99% boondoggle and 1% needed. Patients who have a prescription for an inhaler do not need a nebulizer — but medical suppliers pass them out anyway. Medicare should not pay for nebulized medications in the first place since the usual medications are generic. There is near-universal agreement (except for suppliers) that a meter dose inhaler (MDI) is more effective than a nebulizer. So if Medicare is bent on providing inhaled medication at least provide the cost effective MDI. Canadian doctors rarely find a need for nebulizers because the government provides MDIs.
- Walkers are a good hedge against falling. A broken hip is a lot more expensive than a walker. But, why does Medicare pay $65 for walkers that probably cost $20 to manufacture?
- The idea of letting the supplier get the prescription directly is inviting fraudulent behavior. The local supplier does not have the staff to investigate the truck-loads of rules so what do you think happens? Forms are filled out like the ones that passed the system before, the equipment is delivered (mostly) and Medicare pays.
- Set a national Medicare budget for equipment with some sort of priority if the budget is tight.
- Medicare should nationally purchase large volumes of commonly used equipment then send it to people by UPS or FedEx (like Amazon)
- Physicians should prescribe equipment by computer directly to Medicare (or a national clearing house). Medicare and insurance companies could then monitor the indications electronically before providing the equipment. Also, this would allow contract bidding for the equipment. The equipment vendor makes no decisions except how to deliver the goods.
Laura Landro of the Wall Street Journal published the article: “Image Sharing Seeks to Reduce Repeat Scans” on April 1, 2013. Ms. Landro reported on an academic project to store x-ray pictures on the Internet called the “Imaging Sharing Project” (image share news release). The idea is to have patients own a secure copy of their personal x-rays. By having this storehouse of x-rays in the “cloud” they can be given to any health care provider or hospital as needed.
Any patient who has had to take x-ray images from one provider to another understands the problem. The provider handed the disk of images may or may not be able to look at them because of incompatible ways of recording the material. Of course, this means another visit to the provider (or worse, a repeat x-ray and unnecessary x-ray exposure).
Storage of images is nothing new. But, the concept of the patient owning the images is indeed something new. It allows a patient to seek a second opinion without all the hassle of getting the disk. This is a real asset to a patient who keeps copies of their own medical information. The typed radiologist report is usually very brief and does not allow for alternate interpretations.
The difficulty transmitting images is partly intentional. Radiologists fear someone else far away could be a business competitor. It would be very bad for local radiologists if patients always wanted their brain CT evaluated by some expert in Boston or London.
Cancer patients will find this service very helpful. If a woman has an abnormal mammogram she can pick the oncologist or surgeon and then share the images with them. If she has a mammogram at a different facility she can share the older image for the purpose of comparison.
People who move from city to city would still retain easy access to x-ray images. The US population is much more mobile than in the past so this is very important.
The Image Share project is not available everywhere. There is a commercial product called LifeIMAGE. It is a great idea so hopefully the idea will spread. It would be a step forward if all insurance programs and x-ray offices were required to provide this as a benefit. If you know of other similar products please leave a reply.