Archive for category Evidence based guidelines
Ralph Waldo Emerson is not usually associated with healthcare. However, his famous quote about consistency may apply. The US healthcare system seems to be quite consistent, in a bad way.
The Perspective section of the September 7, 2017 edition of the New England Journal of Medicine featured an opinion article by Eric Schneider and David Squires. The essence of the article is to point out the US healthcare system has a lot of potential, receives lots of money, discovers great treatments and has some institutions that really deliver good care. The authors suggest with a change in focus US healthcare could be number one in the world. Yet, it is not. And, it maintains a poor rating CONSISTENTLY.
The authors state key strategies for improving healthcare:
- Timely access to care (preventive, acute and chronic)
- Delivery of evidence-based and appropriate care services.
They note several things that stand in the way of delivering care of any type:
- Cost of care (US is number one)
- Administrative burden (US is number one)
- Disparities in the delivery of care (US rates very high)
In any large US city the profusion of stand-alone emergency rooms is testament to the failed notion of high-cost rescue treatment rather than low-cost prevention or ongoing monitoring and early intervention. The US tends to invest in high-cost drugs, treatments and surgeries and under-invests in primary care and social services. The failure to adjust the focus of healthcare efforts has become a financial train wreck.
The authors of the above article present four prescriptions for US healthcare:
- Improve access to care
- Increase investment in primary care
- Reduce the administrative burden
- Make healthcare more equitable, so all people can receive good healthcare
However, those lofty goals require something else. The US must stop the foolish consistency of accepting poor health care, of paying too much for healthcare and believing great inventions automatically lead to great healthcare.
Perhaps the Emerson quote is too painful. An Albert Einstein quote may be better:
“The world we have created is a product of our thinking; it cannot be changed without changing our thinking.”
DON’T GET AN ANNUAL EXAM. The data are clear — see the recent article in the New England Journal of Medicine and the op-ed in the New York Times — perhaps you missed this counter-intuitive health advice?
Mechanical devices need preventative maintenance. The aircraft mechanic in the illustration prevents engine failure by checking and replacing parts before they go bad. He knows the MTBF (mean time between failures) for the various engine components. You would think this is how the human body works but THAT’S NOT TRUE. You don’t take out an appendix like a spark plug just because they sometimes go bad — you fix it only when needed because surgery hurts and has complications.
One third of the US adult population get annual physical exams and primary care doctors spend 10% of office visits doing those exams. Sound research shows the annual physical is not needed and worse yet, may be harmful because of false positives (tests that say something is wrong but later are proven wrong). It’s the very essence of a false positive — an abnormal test in a healthy person! You know where that leads: “we need to do some additional tests or a biopsy” — just hope it’s not a brain biopsy.
The US healthcare system needs the wasted 10% of primary care time elsewhere. It’s totally crazy — doctors doing unnecessary annual exams that clog up the appointment calendar and make it hard for people with actual problems to get an appointment. And, a large number of people have health problems who don’t see health care providers when they should (but that’s another story)!
Doctors like to do annual physicals — it’s nice to visit with patients and not have to make any hard decisions. And, they make a lot of money doing the exams under the guise of “maintaining a relationship”. But, the exams are not needed.
A proactive patient would make health care appointments as needed for the following:
- Annual flu shot
- Tetanus vaccination every 10 years.
- Cholesterol test every 5 years
- For women over 40 a pap smear every 3 years and a mammogram every 2 years.
Do you really need to have a health care provider tell you the following things, or is this list enough?
- DO keep weight in normal range (BMI below 25)
- DO walk 30 minutes every day
- DO wear seat belts
- Don’t use drugs or alcohol
- Don’t smoke
- DO Check blood pressure every year (automated checks are just fine)
- DO see a health care provider if you have a health problem.
Keep in mind this discussion is about an exam for nothing in particular — just a “check-up” — which you don’t need. On the other hand, a patient needs visits with a health care provider to treat and monitor abnormal conditions. You need routine visits to adjust blood pressure medications, to treat diabetes, to treat acne and to evaluate arthritis.
A story in Pro-Publica (7/12/15) and reproduced in the Washington Post highlights the problems with anticoagulants when given in nursing homes. The graphic at the left shows the magnitude of the problem — lots of patients in nursing homes get these drugs. The next graphic shows data from North Carolina pinpointing the main culprit: WARFARIN.
What is going on? Well, warfarin is a tricky drug because it changes the body’s system to make the blood clot. Some people tend to clot too much (and get clots in the brain, a stroke, and some people get clots in the lungs, a pulmonary embolus). Those people are at risk of death from too much blood clotting. So, health care providers prescribe an anticoagulant to make the blood clot less easily. Unfortunately, this creates a state where people bleed easily. It is indeed a situation “between a rock and a hard place“.
Warfarin is one of the most common of the drugs for this purpose. It has the advantage of an existing antidote and it is inexpensive. But, it requires frequent blood testing to keep the anticoagulant effects in a reasonably safe range. Providers must order the tests and must change the dose according to the results.
Thrombin inhibitors are a new class of anticoagulants which have the same bleeding risks and are expensive. Their claim to fame is that blood testing is not needed. They also have the disturbing quality of not having an antidote if bleeding starts. Taking all this into consideration, most providers choose the older drug warfarin.
The reasons for excessive bleeding in nursing homes are:
- Prescribers (not the nursing home staff) fail to order blood testing when they should and fail to adjust the medication as they should.
- Prescribers fail to stop anticoagulants when the risk of falling exceeds the risk of blood clotting.
- Pharmacists for nursing home patients are not as connected to their patients as they should be — usually the pharmacist is the safety net for bad prescribing — sadly, they are out of the loop.
- RNs in nursing homes have the training to catch medication errors but function as administrators and are not on the front line of care. Thus, like pharmacists they are not performing the safety net function they might in hospitals or doctor’s offices.
- Elderly patients are the most prone to adverse drug events — for them, if a side effect is possible they will likely experience it. It there is a risk of bleeding they probably will.
What should be done:
- State certification organizations should develop guidelines that require nursing homes and their prescribers to have a protocol for anticoagulation management — not every prescriber can be allowed to invent their own method — that’s the mess we have already!
- Nursing homes should use electronic means to track anticoagulants and the adherence to prescribing protocols. This is not rocket science, those protocols (evidence based guidelines) and computer programs already exist! So, USE THEM.
- Proactive patients and families should ask about the protocol that will be followed for warfarin in the nursing home — if there is no protocol SPEAK UP — show them a copy of this blog.
If your doctor says your kidneys are not working 100% … is that a problem? ABSOLUTELY! You need your kidneys in order to stay alive and when blood tests begin to show kidney problems it means you have lost a lot of kidney function already — at least 50%. So, the wise doctor and the informed patient need to run a checklist to do the right things. If you wait until you have symptoms of complete kidney failure, it’s too late.
The main blood test for kidney function is serum creatinine — abbreviated Cr. The kidneys have a large reserve capacity; in fact, a person can donate a kidney and still have the creatinine (Cr) blood test be “within normal limits”.
Many things can go wrong with the kidneys that range from the fairly simple to the terribly complex. For instance, kidneys can be damaged simply by the bad effects of high blood pressure or by esoteric autoimmune diseases (“friendly fire” where the body’s defense against germs is accidentally directed at healthy kidney tissue).
You need to know 4 things to estimate your kidney function:
- Serum Creatinine (Cr) as measured on a blood sample.
- Your age (in years)
- Your race (black or not-black)
- Your gender (male or female)
Then you calculate another number called eGFR (estimated glomelular filtration rate) based on the items 1 – 4. Often, this is automatically calculated by the lab — if not get the answer from many online web sites like the National Kidney Foundation eGFR calculator. The normal value is 100 but it’s not considered abnormal until it is below 90.
|STAGE||eGFR||DESCRIPTION||TREATMENT (also see tables below)|
|1||90+||Normal kidney function but urine findings or structural abnormalities or genetic traits point to kidney disease.||Observation, control of blood pressure.|
|2||60-89||Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease||Observation, control of blood pressure and risk factors.|
|Moderately reduced kidney function||Observation, control of blood pressure and risk factors.|
|4||15-29||Severely reduced kidney function||Planning for endstage renal failure.|
|5||below 15 or on dialysis||Very severe, or endstage kidney failure (sometimes called established renal failure)||Dialysis or transplant.|
Now to the checklist mentioned above (Clin J Am Soc Nephrol 9:1526-1535,2014.): All is well if you have no known kidney problems, the eGFR is above 90, the urinalysis (U/A) is normal, and you have no genetic predisposition to kidney disease (like a family history of polycystic kidney disease). Otherwise, you have stage 1-4 kidney disease so check off the items below to make sure important tests and treatments are obtained.
Slow the progression.
Find and treat complications.
|Check hemoglobin and Iron — keep in satisfactory range.|
|Check calcium, phosphate and PTH — keep in satisfactory range.|
Referral to nephrologist.
So, this seems complicated? TRUE. That is precisely why a checklist is needed. And, that is why the informed patient needs to go over this checklist with the primary care provider. Print a copy of this post and take it with you to an appointment to start the discussion.
It sounds like a paradox: science studying itself. But, that is exactly what is happening in medicine. Basic research has led to applications of the research and the applications are studied for effects, benefits and cost. For example: invent robotic surgery and apply it to patients, then set it up as a program in an operating room and try to improve the technique and patient selection, and finally evaluate the program to see if it meets stated goals of quality and cost and decide if it should continue and under what conditions.
This huge simplification helps with terms doctors and hospitals often talk about:
- Discover and apply — called research.
- Try to improve — called quality improvement (QI).
- Continue the effort? — called program evaluation (PE).
Patients can be subjects of research. But, participation in research requires explicit permission since the outcome is not known and it could be bad.
If we knew what it was we were doing, it would not be called research, would it? (Albert Einstein)
Patients are hopefully impacted by quality improvement since the purpose is to make things better and thus no patient permission is required. As part of QI a hospital may try to make sure antibiotics are given before surgery because there is research evidence the practice reduces infection. Quality improvement focuses on a cycle of planning, doing, study and revision. QI has become a huge area of study with numerous books and journals on the subject. Virtually every hospital has a quality manager who is charged with improving the care at a hospital.
Patients are only indirectly affected by program evaluation. Clinics and hospitals constantly evaluate programs for positive or negative effects. Whether programs continue depend on such studies. People may read about evaluation of medical programs like care at VA hospitals and may be impacted by decisions of policy makers based on such evaluations. PE is likewise an important and growing discipline.
The concepts of research, quality improvement and program evaluation do tend to overlap. One could imagine using QI techniques to improve the quality of research. And, one could imagine research to find the fastest way to do program evaluation. However, research is mainly for the purpose the researcher decides. Whereas QI and PE are mainly for patient care, business or institutional purposes.
Quality healthcare depends on QI and PE. Patients often don’t see these efforts in action. But, ineffective QI and PE are hazardous to your health. Although doctors and hospitals don’t like the idea: law suits are a warning flag of inadequate QI and PE.
Nancy Morden MD MPH with others from the Dartmouth Institute for Health Policy and Clinical Practice published a nice “Perspective” in NEJM 3694;4:299-302. The essence of the article is the observation that published goals of treatment which don’t specify how to reach the goal lead to prescribers” jumping the gun” with strong expensive medications rather than a prudent step by step approach.
A good example from the article is controlling blood pressure. Guidelines state the desired blood pressure goal is less than 140/90. Prescribers tend to skip dietary management, skip lowering the salt intake, skip reducing alcohol consumption and jump right to strong blood pressure medications (with the attendant drug allergies, risks and costs).
Another criticism is stopping a medication too soon. The example is beta-blocker medication after a heart attack. It is not enough just to start the medication. The medication must be continued indefinitely. Too often the medication is stopped because the reason for starting it is forgotten.
Here are the areas the authors found problematic:
- Blood pressure control
- Cholesterol management
- Diabetes control
- Clot prevention for occlusive vascular disease
- Lipid control for coronary artery disease
- Long term beta-blocker after heart attack
- Avoidance of antibiotics for acute bronchitis
- Drug use generally in the elderly
From the patient standpoint: if a health care provider says you have some condition or diagnosis make sure to ask for a step-wise approach to treatment. In other words, ask for simple or less expensive things to be tried first. Then insist on follow-up to see if the first steps work. If the simple things work, you win. Make sure to research the diagnosis on the internet to exhaust the simple and low cost alternatives. Later, if the simple things are not enough move on to the next step.
There are obviously situations where a slow cautious approach is not correct. If you are having a heart attack or a stroke or a blood clot it’s too late to do simple things.
Make sure to understand how long a medication might be needed — if it is “until something better is found” then stick to it and make sure the providers give a good reason for stopping (particularly if you change providers).
Today, 7/12/13, the Wall Street Journal has a front page story “Hospitals Prescribe Big Data to Track Doctors at Work” by Anna Wilde Mathews. The past 20 years have seen numerous efforts to give performance data to doctors with the hope the doctors will change practice patterns. Each time the efforts have failed. The Wall Street Journal article paints a hopeful picture that faster and more accurate data analysis will finally solve health care quality problems.
Insanity: doing the same thing over and over again and expecting different results. Albert Einstein
Clearly, collecting such data does reveal quality problems. In fact, the first step to correcting quality problems is finding them.
But, there are three fatal flaws in thinking that telling doctors about their own quality problems will really help patients:
- Studies of errors happening with complex tasks show the best human performance is an error rate of 1 – 10 errors per 100 tasks. Meaning, no matter how much you flog doctors with data there is a human limit to performance. Patients want performance in the range of 1 error per million which requires computers and systems.
- By looking at errors as a personal failing instead of a system failure innovation is inhibited. People tend to say “try harder” rather than “try something new”.
- A data driven focus on past problems actually blurs the view of new solutions and new treatments. Decision support can assist physicians to adopt new methods and treatments. Currently it takes about 15 years for proven treatments to enter routine practice — big data does not move that forward.
The electronic medical record (EMR) solves many of the problems (this is not big data but something called decision support). The big data approach is to tell doctors they failed and to try harder in the future. Instead, decision support shows doctors choices at the point of making a decision. For example, as the physician is using the EMR with a patient in the room these messages could show up:
Mammograms: the EMR tells the physician that mammograms will be ordered every year unless you check here [ ].
Tetanus vaccination: your patient has not had a tetanus vaccination. Give the vaccination now? [ ]yes [ ] no
Asthma medications: Refill data suggests the patient is not taking enough controller medication. What is the reason? ___________________.
Chlamydia screening: Your patient (age 16-24) has not had screening. Do it today? [ ]yes [ ] no
Bronchitis treatment: Treatment guidelines for acute bronchitis do not include antibiotics. Is the diagnosis correct?. Consider other agents like cough suppressants or bronchodilators.
Diabetes & blood sugar. Guidelines suggest checking A1C hemoglobin every 3 months for diabetics taking insulin. Order A1C now? [ ]yes [ ]no
Conclusion: It is important to collect data on individual doctors and on hospital systems. That data can tell whether quality improvement efforts are working. But, doctors need computer driven decision support at the time of ordering treatment or tests, not criticism days or months later. Patients benefit immediately from decision support but only later, if at all, from big data.
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.
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.
The ABIM foundation asked all the major medical and surgical specialty societies in the US to each submit “Five Things Physicians and Patients Should Question“. The specialty societies picked five tests or procedures they thought were being overused or wasteful. Each one of the “things” is an important well researched piece of advice the societies believe health care providers and patients should know. Who is doing the questioning is not clear — but it seems if providers are not following the advice then other doctors, quality assurance departments and patients themselves should ask questions.
The assortment of ABIM documents is mainly intended for physicians so they do contain technical terms. Fortunately, the ABIM partnered with Consumer Reports to write FREE consumer friendly versions of the ABIM recommendations. The site has a nice navigation bar so you can quickly find helpful information. Here is a link to the site: Consumer Health Choices.
The author of this blog created an abridged version for a quick scan of everything to date. Take your choice, either the original, the Consumer Reports version or the abridged (no beating around the bush) version. A few societies have not yet submitted information so check back with the ABIM Foundation site later if interested.
There seem to be some common threads in the advice:
- Don’t do tests if there is no plan to act on the tests (or to find a disease that has no treatment)
- Don’t do screening tests if testing errors cause unnecessary or harmful surgery or other tests.
- The time interval for screening tests is very important (especially for cost reasons)
- Imaging (nuclear scans, CT, MRI, PET, ultrasound etc.) has been massively overused — always question whether imaging is needed.
- In general, don’t fix things that don’t eventually cause symptoms
The advice is both favorable for patients and favorable to reduce the cost of health care. The US needs more of these evidence-based guidelines.