Health Care Policy

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Transforming Practices

Transforming Practices

A new study shows how an HMS initiative has been improving primary care for thousands across Boston.

By MEGAN PROCK
Mon, 2014-07-14

Center for Primary Care leader Russ Phillips, center, teaching a class.  Image: Courtesy CPC

A new paper in Academic Medicine shows that a Harvard Medical School team-based primary care initiative at 19 local practices resulted in substantial improvement across all identified areas of transformation.

This novel, two-year learning collaborative, launched by the Harvard Medical School Center for Primary Care, consists of hospital- and community-based primary care teaching practices that serve more than 260,000 patients and train more than 450 residents in the greater Boston area.

In 2012, in response to a rapidly changing health care landscape, the Center for Primary Care, in partnership with local academic medical centers, established an academic innovations collaborative (AIC) to spur practice transformation across 6 Harvard-affiliated entities: Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Cambridge Health Alliance, Boston Children’s Hospital, Massachusetts General Hospital and Mount Auburn Hospital.

The center built a collaborative structure and learning model in concert with Qualis Health and the Institute for Healthcare Improvement that has made a demonstrable change in the ways that practices function and engage patients and trainees in transformation.

“In two years we have successfully created a dynamic learning community that promotes team-based care and has fundamentally transformed care at 19 complex academic medical practices that serve diverse patients populations in the greater Boston area,” said Andrew Ellner, co-director of the Center for Primary Care and HMS assistant professor of medicine at Brigham and Women's.

“This level of collaboration across hospital systems is unprecedented in our community and holds tremendous promise for the future,” Ellner said.

Through the AIC, practices made substantial (more than 25 percent) and statistically significant improvement in scores across all areas of practice function on the validated Patient-Centered Medical Home Assessment tool including:

  • Team-based primary care
  • Leadership engagement
  • Quality improvement
  • Evidence-based care
  • Patient engagement
  • Access
  • Care coordination 

Important factors for success included leadership development, practice-level resources, and engaging patients and trainees.

“Lately, some health experts have been debating whether the patient-centered medical home is ‘the answer’ to the challenges primary care faces. Our work suggests that the AIC model of change shows promise as a path for academic medical centers to catalyze health system transformation through primary care improvement,” said Asaf Bitton, faculty lead for transformation strategy and design in the academic innovations collaborative and assistant professor of medicine at Brigham and Women's.

In addition to next steps for further evaluating the impact of practice transformation on quality measures and costs, expansion of the AIC model will require support from academic medical centers and payers, and the application of similar approaches on a broader scale in other medical training environments.

“The work of the AIC is not done. We are now entering a second phase, in partnership with CRICO/Risk Management Foundation of the Harvard Medical Institutions, in which we will focus on expanding team-based care to further optimize patient safety and care,” said Ellner. “We look forward to learning how a novel collaborative of this nature can help us provide the highest possible standard of primary care.”

About the Center for Primary Care

The HMS Center for Primary Care was launched on October 28, 2010. The center’s mission is to improve the health of our communities through transformation in primary care practice and education. Learn more at: https://primarycare.hms.harvard.edu/

 

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Unintended Danger from Antidepressant Warnings

Unintended Danger from Antidepressant Warnings

When treatment of youth went down after media coverage of drug warnings, suicide attempts went up

By JAKE MILLER
Wed, 2014-06-18

Image: iStockPhoto

Researchers have found that U.S. Food and Drug Administration warnings about a potential danger for young people taking antidepressants may have backfired, causing an increase in suicide attempts by teens and young adults.

The 2003 warnings drew intense and possibly exaggerated media coverage that led to a sudden, steep decline in the number of prescriptions for antidepressants without offsetting increases in other effective treatments. In a study published in BMJ, researchers at Harvard Medical School’s Department of Population Medicine and the Harvard Pilgrim Health Care Institute report that in the year following the warnings, when antidepressant prescriptions fell by more than a fifth among young people, there was a relative increase of 21.7 percent in suicide attempts by overdose with psychotropic drugs, and 33.7 percent among young adults.

“This study is a one of the first to directly measure a health outcome driven by the interaction of public policy and mass media,” said Christine Lu, HMS instructor in population medicine at Harvard Pilgrim Health Care Institute and lead author of the study. “The FDA, the media and physicians need to find better ways to work together to ensure that patients get the medication that they need, while still being protected from potential risks.”

“This is an extraordinarily difficult public health problem, and if we don’t get it right, it can backfire in serious ways,” said co-author Stephen Soumerai, HMS professor of population medicine at Harvard Pilgrim Health Care Institute.

In 2003, an analysis that combed through all the existing clinical trials noted that approximately 1 percent of adolescents and young adults taking antidepressants experienced an increase in thinking about suicide.

The original warning, which was heavily publicized in news reports, mentioned only this potential risk of antidepressants to patients without noting the potential risk of undertreatment of depression.

These well-intended safety warnings became frightening alarms to clinicians, parents and young people, the researchers note, with many prominent media outlets warning that these drugs raised the risk of suicide. However, the FDA-cited studies showed only an increase in the risk of suicidal thoughts, not in attempted or completed suicide. In fact, as more young people were prescribed antidepressants in the years before the warning was issued, suicide attempts by young people were stable, the researchers said.

The FDA later revised the warning to recommend that physicians consider both the risk of prescribing the medication and the risk of not prescribing the medication, monitoring patients for thoughts of suicide and treating them as needed. 

“These drugs can be very effective,” Soumerai said. “The media concentrated more on the relatively small risk than on the significant upside.”

The risks cited by the FDA were about 1 percent of those treated, but antidepressant use dropped suddenly by about a relative 20 percent, unintentionally leaving many depressed young people without appropriate treatment, which likely drove the accompanying hospital and emergency department admissions for suicide attempts, he said.

The researchers analyzed claims data for the years 2000 to 2010 from 11 health plans in the U.S. Mental Health Research Network, using a “virtual data warehouse” with anonymous patient data organized to facilitate sharing and data comparison between health systems. The study cohorts included 1.1 million adolescents, 1.4 million young adults and 5 million adults.

The researchers used overdose with psychotropic drugs as a conservative measure of suicide attempts. Completed suicides are very rare, so the researchers were not surprised to find no change in their 7.5 million patient sample.

The researchers noted that suicide attempts with drug overdose are very serious, resulting in long-term hospitalization and significant disruption to the lives of patients and their families.

“We need to do a better job of understanding and communicating the risks of taking—and not taking—medications,” Lu said.

This research was supported by a cooperative agreement (U19MH092201) with the U.S. National Institute of Mental Health.

All authors have support from the National Institute of Mental Health for the submitted work. Individual authors also report receiving grants and personal fees from Policy Analysis Inc. and Bristol-Myers Squibb outside this work.

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$1.9 Billion in Medicare Waste: Tip of the Iceberg

$1.9 Billion in Medicare Waste: ‘Tip of the Iceberg’

Findings provide tools for evaluating reform efforts

By JAKE MILLER
Mon, 2014-05-12

Image: iStockPhoto

In the first large-scale study to directly measure wasteful spending in Medicare, researchers found that Medicare spent $1.9 billion in 2009 for patients to receive any of 26 tests and procedures that have been shown by empirical studies to offer little or no health benefit.

By analyzing Medicare claims data, researchers in the Harvard Medical School Department of Health Care Policy found that at least one in four Medicare recipients received one or more of these services in 2009. What’s more, those 26 services are just a small sample of the hundreds of services that are known to provide little or no medical value to patients in many circumstances.

“We suspect this is just the tip of the iceberg,” said study author J. Michael McWilliams, associate professor of health care policy. The study appears today in JAMA Internal Medicine.

The researchers said that the methods utilized in the study will provide useful tools for measuring the effectiveness of reform efforts, like those in the Affordable Care Act, aimed at reducing wasteful spending in Medicare and across the health care system.

Pervasive waste

Health care spending in America is at an all-time high and continues to rise. Efforts to curb wasteful spending in Medicare and throughout the health care system are crucial to attempts to reduce spending while improving or at least preserving quality of care.

“We were surprised that these wasteful services were so prevalent,” said Aaron Schwartz, an MD/PhD student in the HMS Department of Health Care Policy and lead author of the study. “Even just looking at a fraction of wasteful services and using our narrowest definitions of waste, we found that one quarter of Medicare beneficiaries undergo procedures or tests that don’t tend to help them get better.” 

Previous attempts to measure waste in Medicare and other health care systems have relied on comparing overall spending rates between matched patient populations in different geographical areas. The difference between the higher and lower spending areas is attributed to waste. In addition to giving researchers and policy makers a tool to more precisely measure existing waste, the methods used by the researchers can also provide important feedback on reforms designed to curb waste.

Hard to define

Some of the services studied—like arthroscopic debridement for knee osteoarthritis and a form of back surgery that involves filling collapsed disks with cement—almost never provide any health benefit to patients, and are almost always wasteful, according to recent empirical studies of the effectiveness of the procedures. Others are often wasteful but can provide profound benefits for patients in particular clinical circumstances. Lower back imaging for general back pain offers little benefit to patients with muscle soreness, but it can be lifesaving when used to identify cancer or a spinal abscess.

Choosing from hundreds of services that have been found to have little clinical value, the researchers identified 26 that would be detectable using the kind of information available in Medicare claims data. They then searched for examples of the 26 services that were likely wasteful among the claims records of 1,360,908 Medicare beneficiaries from 2009.

The researchers found that varying the criteria used to count wasteful instances of a service can substantially influence the amount of waste measured. A narrower definition would exclude likely beneficial cases but would miss counting some instances of waste. A broader definition would capture more instances of wasteful use, but would also inadvertently count some services that were medically beneficial.

The estimate of overall waste with the narrower criteria found that 25 percent of beneficiaries received at least one of the wasteful services, resulting in a total of $1.9 billion in Medicare spending. The broader version found that 42 percent of beneficiaries were affected at a cost of $8.5 billion in potentially wasteful spending.

“One of the things we learned from this study is that measuring waste is hard,” Schwartz said. “How much waste you find varies greatly depending on how you define it. Removed from the clinical details of a particular patient, it is hard to know whether a given procedure might be useful or not.”

Measuring reform

“Because the value of a service depends on the patient, it is challenging to devise payment and coverage policies that limit wasteful care but not valuable care. Some tests and treatments that are wasteful across the board are easy targets—we can stop paying for them. But for most services, incentives that allow providers greater discretion at the point of care may be needed to cut significant amounts of waste while minimizing unintended consequences,” said McWilliams, who is also a practicing general internist at Brigham and Women’s Hospital

Instead of limiting care through coverage design or payment restrictions, the researchers see potential in global payment models that replace fee-for-service reimbursement with incentives to keep spending within a global budget and improve quality of care. These models could allow physicians and provider organizations to use more detailed clinical information to identify many more low-value services while encouraging their elimination. There are numerous low-value services—identified for example by specialty societies through campaigns like Choosing Wisely—that are difficult to measure well with claims data but could nevertheless be targeted by such broader payment reforms.

“That’s the theory behind reform experiments being implemented under the Affordable Care Act and through private insurers,” Schwartz said. “It’s exciting that we now have a tool to measure how well global budgets and similar reforms perform at the specific task of cutting wasteful spending.”

Funding: Supported by grants from the Beeson Career Development Award Program (National Institute on Aging K08 AG038354 and the American Federation for Aging Research), Doris Duke Charitable Foundation (Clinical Scientist Development Award #2010053), National Institute on Aging (P01 AG032952), Agency for Healthcare Research and Quality Institutional Training Grant (2T32HS000055-20), Harvard University (Christopher G.P. Walker Fellowship), and the Australian National Health and Medical Research Council Sidney Sax Public Health Fellowship (627061).

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The Mammography Dilemma

The Mammography Dilemma

Complex benefits and harms of mammography require individualized approach

By JAKE MILLER
Tue, 2014-04-01

Image: iStockPhoto

A comprehensive review of 50 years’ worth of international studies assessing the benefits and harms of mammography screening suggests that the benefits of the screening are often overestimated, while harms are underestimated. And, since the relative benefits and harms of screening are related to a complex array of clinical factors and personal preferences, physicians and patients need more guidance on how best to individualize their approach to breast cancer screening.

The results of the review by researchers at Harvard Medical School’s Department of Health Care Policy and Brigham and Women’s Hospital are published today in JAMA.

The American Cancer Society estimates that about 40,000 U.S. women will die of breast cancer this year. In 2009, based on evidence that the benefit-risk ratio for mammography screening is higher among women over 50 and with less frequent screening, the U.S. Preventive Services Task Force (USPSTF) reversed its previous recommendation of mammography every one to two years beginning at age 40, and recommended routine screening every two years starting at age 50, the researchers noted. The recommendations remain controversial among the general public and the medical community. Recent evidence suggests that use of mammography in the U.S. has not changed following the updated recommendations.  

“What I tell my patients is that the mammogram is not a perfect test,” said Nancy Keating, co-author of the report, associate professor of Health Care Policy at HMS and associate professor of medicine at Brigham and Women’s. “Some cancers will be missed, some people will die of breast cancer regardless of whether they have a mammogram, and a small number of people that might have died of breast cancer without screening will have their lives saved.”

The authors report that the best estimate of the reduction in mortality from breast cancer due to annual screening for women overall is about 19 percent. For women in their 40s, the reduction in risk was about 15 percent, and for women in their 60s, about 32 percent. But how much a woman benefits depends on her underlying risk of breast cancer. Moreover, mammography is associated with harms that may be shared by all women who receive the screening tests, not just the women who eventually benefit from them.

The researchers estimated that among 10,000 women in their 40s who undergo annual mammography for 10 years, about 190 will be diagnosed with breast cancer. Of those 190, the researchers estimate that about 5 will avoid death from breast cancer due to screening. About 25 of the 190 would die of breast cancer regardless of whether they have a mammogram or not. The rest will survive, thanks largely to advances in breast cancer treatment.

However, according to Keating, the chief harm associated with mammography is the risk of overdiagnosis. This is the diagnosis of cancers that never would have become clinically evident during a woman’s lifetime, either because the cancer never grew or because the patient died first of another cause. While it is impossible with current techniques to know which cancers we could safely observe and which need to be treated, the review cites findings that roughly 19 percent of women who are diagnosed based on findings from a mammogram are overdiagnosed. That means that roughly 36 of the 190 women who received annual mammography for 10 years and were diagnosed with breast cancer would receive unnecessary surgery, chemotherapy or radiotherapy. 

In addition, more than half of women who get annual screenings for 10 years can expect to have a false positive mammogram that requires additional images, and about 20 percent of these false positives result in unnecessary biopsies. Studies show these false positives cause some short-term anxiety, but there is not consensus about lasting harm.

“While we need more research on mammography’s benefits and harms today, existing data suggest that we have been overestimating the benefits of mammography and underestimating the harms over the years,” said co-author Lydia Pace, research fellow in Women’s Health at Brigham and Women’s. “It is really important to have informed discussions with our patients to help them understand the chances that a mammogram will benefit them as well as the possible downsides of getting a mammogram, so that they can incorporate their own values and preferences in making the right decision for themselves.”

Breast cancer risk rises with age, so women in their 50s and 60s receive more benefit relative to the risk of harm. Other factors, including family history and whether and when a woman has given birth, also change a woman’s risk/benefit ratio.

Keating emphasized the importance of individualizing screening recommendations based on a patient’s personal profile. Overdiagnosis is a particular concern among women with limited life expectancies, either due to age or some other condition. “I have 80-year-olds in my practice with life expectancies of 15 or 20 years, and 60-year-olds who will likely only live another year or two,” she said. “Those two kinds of patients need different recommendations about whether to continue screenings, and it can’t be based simply on the patient’s age.”

The researchers said that they hope that this systematic review of the literature on the risks and rewards of mammography for patients will help physicians understand the complex data, and will encourage the development and use of tools for customizing the information they share with their patients to meet each patient’s individual needs. The researchers also noted that more work needs to be done to fully understand the harms of mammography.

Pace’s effort on this review was funded by the Global Women’s Health Fellowship at Brigham and Women’s Hospital.

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Suicidal Ideation Among U.S. Soldiers Precedes Enlistment

Suicidal Ideation Among U.S. Soldiers Precedes Enlistment

Early interventions might hold the key to reducing the high Army suicide rate

By JAKE MILLER
Mon, 2014-03-03

Image: U.S. Army photo by Spc. Steven HitchcockNearly 60% of soldier suicide attempts can be traced to pre-enlistment mental disorders, which are much more common among nondeployed U.S. Army soldiers than demographically similar populations of civilians (25.1% vs. 11.6%), according to a major new study. The vast majority (76.6%) of soldiers with mental disorders say their conditions started before enlistment, researchers found.

These are among the initial results published online today in JAMA Psychiatry based on a survey carried out as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), the largest study of mental health risk and resilience ever conducted among U.S. Army personnel.

Although the suicide death rate in the U.S. Army has historically been below the civilian rate, the Army rate began climbing at the beginning of the Iraq and Afghanistan conflicts, and by 2008, it exceeded the demographically matched civilian rate (20.2 suicide deaths per 100,000 vs. 19.2). Concerns about this increase led to Army STARRS, a partnership between the Army and the NIMH designed to help understand and address this issue. The initial findings published today include three papers that use different strategies to evaluate suicide risk and protective factors among service people, including an analysis comparing the prevalence of mental disorders among Army and civilian populations.

“Some of the differences in disorder rates are truly remarkable,” said Ronald Kessler, McNeil Family Professor of Health Care Policy at Harvard Medical School and senior author of the paper on mental disorder prevalence. “The rate of major depression is 5 times as high among soldiers as civilians, intermittent explosive disorder 6 times as high, and PTSD nearly 15 times as high.”

The most common disorders in the Army STARRS survey were attention deficit hyperactivity disorder (ADHD) and intermittent explosive disorder (IED), or recurrent and uncontrollable anger attacks, Kessler said.

The findings suggest that soldiers did not have higher rates of most “internalizing disorders” (anxiety disorders and depression) than civilians before enlistment, but rather developed high rates of these disorders only after they enlisted in the Army. The situation was different, though, for “behavioral disorders” (ADHD, IED and substance abuse), which were much more common among young people who subsequently enlisted in the Army than those who did not. Rates for these disorders increased even more after enlistment. Nearly half of current soldier internalizing disorders and 80% of behavioral disorders started before enlistment.

“These results are a wake-up call highlighting the importance of outreach and intervention for new soldiers who enter the Army with pre-existing mental disorders,” said Robert Ursano, Chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences and co-principal investigator of Army STARRS.

A second Army STARRS paper appearing today in JAMA Psychiatry revealed that 13.9% of soldiers considered suicide at some point in their lifetime, 5.3% had made a suicide plan, and 2.4% had attempted suicide, with between 47% to 60% of these outcomes first occurring prior to enlistment. Pre-existing mental disorders were found to be by far the strongest predictors of these suicidal behaviors.

“It is striking that nearly 50% of the soldiers who attempted suicide made their first attempt before joining the Army, as applicants are asked about any history of suicide attempts in recruitment interviews and those who report such a history typically are excluded from service,” said Matthew Nock, professor of psychology at Harvard University and lead author of this report on soldier suicidality.

Nock noted that the most practical implication of this finding might be that the Army should develop outreach and intervention programs for new soldiers based on the realization that a nontrivial proportion of new soldiers come into the Army with a history of mental disorder and suicidality, and that applicants are not always forthcoming about these concerns during the recruitment process.

The researchers added that intermittent explosive disorder is of special importance because it was the only disorder found to predict suicide attempts after developing suicidal thoughts, which has important implications for screening and prevention. This important finding shows that it is not only depression and PTSD that predict suicide attempts.

A third JAMA Psychiatry article by lead author Michael Schoenbaum of NIMH examined the suicide and accident death rates in relation to basic sociodemographic and Army experience factors in the 975,057 regular Army soldiers who served between Jan. 1, 2004, and Dec. 31, 2009, charting variations in the rates based on a variety of factors including sex, race, education level and rank.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is funded by the U.S. Army and the National Institute of Mental Health. The study is led by co-principal investigators Robert J. Ursano (Uniformed Services University of the Health Sciences) and Murray B. Stein (University of California, San Diego), with site investigators Steven G. Heeringa (University of Michigan) and Ronald C. Kessler (Harvard Medical School), and with collaborating scientists Lisa J. Colpe (NIMH), and Michael Schoenbaum (NIMH). More information at: http://www.armystarrs.org/media_room

 

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Opioid Risks

Opioid Risks

Multiple prescribers for opioids is common in Medicare and increases patient risks

By JAKE MILLER
Wed, 2014-02-19

Image: iStockMore than 30 percent of Medicare beneficiaries who receive opioid prescriptions get these prescriptions from multiple providers, raising the risk of hospitalization from narcotics-related conditions such as injuries from falls, altered consciousness and respiratory depression for millions of patients.

The findings, reported today in BMJ, come in the midst of what the Centers for Disease Control calls a nationwide epidemic of prescription drug overuse and abuse.

From 1991 to 2009, prescriptions for opioid analgesics increased almost threefold in the United States, to over 200 million per year, according to the NIH. While opioids are important painkillers that fill a crucial clinical need, they also have many associated risks. The CDC notes that drug overdose rates in the U.S. have more than tripled since 1990.

Physicians have argued that obtaining opioid prescriptions from more than one provider can increase the risks of taking these medications, but no comprehensive study has been done which document the extent of multiple-provider prescribing and its associated consequences for patient health.

Anupam Jena, study author and assistant professor of Health Care Policy and Medicine at Harvard Medical School and physician at Massachusetts General Hospital, knows that some of the patients he sees who are taking opioids are likely getting prescriptions for the medication from more than one doctor. While this goes against the standard of care, it occurs nonetheless.

Jena and colleagues looked at a sample of 20 percent of subscribers to Medicare’s prescription benefit, or Medicare Part D, from 2010, including 1.8 million beneficiaries who filled at least one opioid prescription that year. When the researchers analyzed the prescriptions patterns, Jena was surprised at how common multiple-prescribers were.

“I thought it would be 5 to 10 percent,” Jena said. “When we ran the numbers and it turned out to be 30 percent, we were shocked.”

They also found a strong correlation between the number of prescribers for a patient and the patient’s risk of an opioid-related hospitalization. Patients who received their opioid prescriptions from more than one doctor were at a significantly greater risk of hospitalization from complications of narcotic use than patients with a single provider managing their opioid prescriptions, and risk went up with the number of prescribers.

“Patients with four or more prescribers were twice as likely to be hospitalized for narcotics-related complications than patients receiving the same number of prescriptions from a single caregiver,” said Professor Pinar Karaca-Mandic, a study co-author and assistant professor at University of Minnesota School of Public Health.

Jena believes that these findings provide important insight into the risks of fragmented care in opioid prescribing.  Many health systems and state governments are building and piloting tools that will make it easier for physicians to monitor whether their patients are already receiving opioid prescriptions from another provider, Jena said, but doctors need to make sure that they communicate to patients the unique risks of fragmented opioid prescribing.

“As physicians, we tell patients not to drive when they take opioids, but we also need to tell them that it can be dangerous to receive these medications from more than one provider. And we need to use tools like Massachusetts’ new drug monitoring program to follow up and make sure that doesn’t happen,” Jena said.

Jena collaborated with Dana Goldman, Leonard D. Schaeffer Chair in Medicine and Public Policy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California; RAND Corporation; Lesley Weaver, graduate student at the University of Minnesota School of Public Health; and Pinar Karaca-Mandic, assistant professor, University of Minnesota School of Public Health.

This study was funded by the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01), the National Institute on Aging (Grants 5P01AG033559 and 5K01AG036740) and a University of Minnesota Academic Health Center Faculty Development Grant.

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The July Effect

The July Effect

Real danger exists for high-risk patients when trainees take on new roles

By JAKE MILLER
Wed, 2013-11-06

Image: iStockPhoto

With almost no experience, newly graduated medical students enter teaching hospitals around the country every July, beginning their careers as interns. At the same time, the last year’s interns and junior residents take a step up and assume new responsibilities.

In addition to developing their nascent clinical skills, each entering class of interns must grasp the many rules and standards for operating in this “new” hospital structure.

More experienced physicians share a joke about this changing of the guard: Don’t get sick in July.

But the data to back up this quip has proven hard to find. Over the years, numerous studies have shown no effect or very slight effects when comparing patient outcomes in July versus the preceding May, when trainees are more experienced and concluding their training cycles. Some researchers have suggested that the safeguards academic medical centers put in place, such as increased supervision by more experienced doctors during this first phase in the training cycle, protect patients from the effects of inexperience and organizational disruption.

A new study published Oct. 23 in Circulation by researchers at Harvard Medical School, Stanford University Hospitals, University of Southern California and the RAND Corporation has found that while the so-called “July effect” is negligible in most cases, it is a serious concern for high-risk patients.

“The good news for patients is that in most cases, it’s very difficult for a physician to make a mistake that results in a patient’s death,” said Anupam Jena, HMS assistant professor of health care policy and of medicine at Massachusetts General Hospital and lead author of the study. “But for severely ill patients, health can be very tenuous. A small error or a very slight delay in care is potentially devastating.”

Jena and colleagues analyzed cases from more than 1,400 hospitals using data from the U.S. Nationwide Inpatient Sample. They compared patients who came to teaching and non-teaching hospitals with acute myocardial infarctions, commonly known as heart attacks. The researchers separated cases into low-risk and high-risk categories and compared outcomes.

Overall, they found that patients at teaching hospitals had a lower risk of dying than at non-teaching hospitals, but in July, the risk at teaching hospitals rose to the same level that patients at non-teaching hospitals faced. For high-risk patients who came to the teaching hospitals with heart attacks, the risk of death in hospital went from 20 percent to 25 percent. They also found that among teaching hospitals, the difference between outcomes in May and July is greatest in institutions with the highest percentages of trainees.

The researchers ruled out two potential factors that they suspected may have accounted for some of that difference—the prevalence of percutaneous coronary intervention (i.e. cardiac stents) and of complications from the use of blood thinners.

Without evidence for specific procedures or protocols that could prevent increased deaths, the researchers said that their findings suggest that, especially during the early months in the training cycle, oversight should be intensively focused on high-risk cases rather than across cases overall. In July, doctors with more experience should play a greater role in the care of high-risk patients than has typically been the case.

“Teaching hospitals should revisit what steps are needed to safely and effectively care for high-risk patients in July,” Jena said.

FUNDING

Support was provided by the Office of the Director, National Institutes of Health (1DP5OD017897-01), the National Institute on Aging (1R03AG031990-A1), and the Leonard Schaeffer Center for Health Policy and Economics at the University of Southern California.

 

 

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Changing Course

Changing Course

Why physicians, politicians and communities must work together for better health

By JAKE MILLER
Thu, 2013-10-24

Josh Sharfstein, Secretary of Health and Mental Hygiene in Maryland delivers the annual Seidman Lecture. Image: Steve LipofskyIn an oddly quiet hospital in rural Maryland, the hospital CEO is delighted that the facility is running at only 60 percent of capacity.

“It’s like the anti-gravity zone for how the health care system usually is,” said Josh Sharfstein, Secretary of Health and Mental Hygiene in Maryland.

Sharfstein was describing a scene from one of his visits to a hospital that was participating in one of a series of experiments designed to make Maryland more healthy.

In this case, the hospital receives a set budget for the year, which it must use to care for the members of the community it serves. Under this system, the hospital is better off financially when it helps patients stay well, as opposed to the fee-for-service system that predominates in the U.S., where hospitals earn more money every time a patient comes to the hospital.

“At this hospital, they’ve had a culture change that isn’t quite, ‘We hope to never see you again,’ but it’s close: ‘We want you to be healthy and not come back,’ ” said Sharfstein, speaking at the 13th annual Seidman Lecture, hosted by the Harvard Medical School Department of Health Care Policy.

“Compare that to hospitals that are advertising on the highway: ‘Two minute wait in our ER, come on in,’ ” he said.

Sharfstein cited examples from other Maryland hospitals, including one that took on responsibility for the local community’s school nurse program. The hospital administrators realized that investing in school nurses would be a more effective and less expensive way of caring for children with chronic conditions such as asthma, which are often left untreated until they are so severe that costly hospitalizations are required.

The traditional health care system is aligned to promote growth, not health: more patients and more procedures mean that more money circulates in the system, Sharfstein said.

One of the key obstacles to effective health care reform across the U.S. is that this misalignment prevents innovative solutions from taking root. “Until you can turn that ship overall, it’s hard to get these good things to happen,” he said.

Complex, long term tasks like reforming the entire U.S. health care system aren’t the only challenges that require collaboration, Sharfstein said. Even simpler and more acute problems require multiple sectors to work together toward the goal of increasing health.

Sharfstein is a pediatrician and an alumnus of Harvard University who served as investigator and health policy adviser on the House Committee on Oversight and Government Reform, as Commissioner of Health for Baltimore City, as a health policy adviser to the 2008 Obama campaign and transition team and as principal deputy commissioner for the FDA.

Drawing on these experiences, he shared a series of case studies that highlighted the need for cooperation between physicians, politicians, public health officers, researchers, journalists and community members.

In one case, Sharfstein told the story of a friend, a dermatologist who saw a baby at a Philadelphia hospital with what looked like a severe diaper rash. It turned out to be a case of malnutrition caused by a diet of rice beverage, which, although it contains virtually no protein, was at the time advertised as a nutritionally complete dairy replacement drink. While that baby recovered, a literature search showed that other children had died from the same condition.

The dermatologist who first saw the baby didn’t stop when he referred the child for a dermatological consult. He wrote a paper for a medical journal, he contacted the press, he reached out to the manufacturers of the beverage, and he called his friend, who happened to be working for Congressman Henry Waxman at the time. Waxman contacted the companies and the FDA. The companies agreed to change the labeling on rice beverages to help keep other children healthy.

Sharfstein also noted that physicians and academic researchers who are interested in effecting change should think about working outside the bounds of academic publishing and medicine.

“As you think about problems and solutions, it’s important to think about where decisions could be made and try to be strategic about bringing that data to the right place,” Sharfstein said.

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Persistent Gender Pay Gap

Persistent Gender Pay Gap

Male physicians still earn 25 percent more than their female colleagues

By JAKE MILLER
Thu, 2013-09-12

Image: iStockPhoto

The income gap between men and women in the United States has been closing over the last quarter century, but not among physicians.

The earnings of male physicians exceed those of female physicians by 25 percent, a trend that has held steady from 1987 to 2010, according to a study published Sept. 2 in JAMA Internal Medicine.

Over those same years, the male-female earnings gap in the general population closed from 28 to 15 percent, the researchers found.

Meanwhile, the percentage of female physicians rose from 10 percent to 28 percent, and women now make up about half of medical school graduates.

“Given that in the overall economy women have now closed more than half the gender income gap that was present in the late 1980s and given that many more physicians are now women, we were surprised to find such persistent income disparity between men and women in medicine,” said study author Anupam Jena, assistant professor of health care policy and medicine at Harvard Medical School and general internist at Massachusetts General Hospital.   

The study, conducted with collaborators at the University of Southern California and Harvard Kennedy School, was based on nationally representative data from the Current Population Survey (CPS), which is collected by the U.S. Census Bureau and the U.S. Bureau of Labor Statistics.

The study compared trends in male and female physician earnings with earnings of other health care professionals and with the general population over three periods from 1987 to 2010. The researchers corrected for the number of hours worked and adjusted all of the figures to 2010 dollar amounts.

There are several causes for the disparity in pay, the researchers said.

One is that women are more likely than men to choose specialties like pediatrics and family medicine that offer more patient interaction and longitudinal relationships with patients, but are often lower paying than other specialties. But it’s unclear whether women chose those specialties out of personal preference, or because they face obstacles in choosing other specialties.

The CPS does not collect data about physician specialty, so this paper does not correct for differences in specialty pay. Instead of comparing male dermatologists to female dermatologists, for example, the study compares a sampling of male physicians from many specialties with a sampling of female physicians.

“Without a better understanding of the underlying causes for those choices, we can’t simply conclude that just because women choose different specialties, pay disparity isn’t an issue,’” Jena said.

It’s possible, he noted, that in 1987 women had equal access to opportunities in medicine and that the choices that they made then—to go into specialties that are lower paid, to work fewer hours, or to join practices that pay less because of either lifestyle factors or location—are the same as the choices they're making now.

However, it is also possible that women would prefer other specialties, but that whatever barriers to opportunity that existed in 1987 have not been eliminated in a significant way. 

“If women choose to work in these particular specialties because of personal preferences, that’s not necessarily an issue,” Jena said. “However, if women choose not to work in particular specialties because of perceived or experienced biases, or because there are few successful senior women in the fields to serve as mentors, that’s a problem.”

The researchers noted that, while much of the income difference between men and women in medicine may be attributed to the relative numbers of women and men in specialties with different earnings potentials, there is also evidence that even within specialties male physicians continue to be better paid than females.

For example, among physician researchers, when you look at those who have the same number of publications, the same levels of NIH funding, the same tenure status, females earn significantly less than males, Jena said.

“It is critical to understand the overall income patterns among the profession, as well as the disparity within specialties, in order to assess the efficacy of educational and professional policies that are designed to promote gender income equity,” Jena said.

This study was supported by a grant from the National Institute of Aging (P01 AG19783-02).

 

 

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Contagious Savings

Contagious Savings

Lower costs from commercial Alternative Quality Contract spill over to patients not covered by the plan

By JAKE MILLER
Tue, 2013-08-27

A commercial health insurer’s large scale demonstration program designed to improve quality and lower costs for subscribers also lowered costs for Medicare patients who used the same health care providers but were not covered by the plan.

 “These findings suggest that provider groups are willing—and able—to make systemic changes that result in higher-value care for patients across the board,” said author J. Michael McWilliams, assistant professor of health care policy and medicine at Harvard Medical School and a practicing general internist at Brigham and Women’s Hospital.

The results are in the August 28 issue of JAMA.

J. Michael McWilliams. Photo courtesy of Brigham and Women's Hospital.McWilliams, along with Michael Chernew and Bruce Landon, both HMS professors of health care policy, examined whether the Blue Cross Blue Shield of Massachusetts (BCBS) Alternative Quality Contract (AQC), an early commercial accountable care initiative associated with reduced spending and improved quality for BCBS enrollees, was also associated with changes in spending and quality for Medicare beneficiaries who were not covered by the AQC.

The researchers found that, within two years, providers who were part of the AQC achieved significant savings (more than 3 percent) for the Medicare beneficiaries they served relative to a control group served by other providers. Quality metrics for the patients in the intervention group either went up or stayed level, meaning the overall value of care rose.

In an accountable care organization (ACO), health care providers assume some financial risk for the costs and quality of the care they deliver. For example, instead of receiving a set fee for each service delivered , provider organizations might receive an annual global budget to care for their patient population. In a two-sided risk-sharing agreement like the AQC, if spending exceeds the budget, the ACO loses money; if spending falls below the budget, the ACO shares in the savings. ACOs also have financial incentives to meet certain quality-of-care goals. Typical goals might include decreased levels of readmissions for patients who are hospitalized, and increased levels of preventive care to help patients remain well.

ACOs are an integral part of many public and private efforts to reform health care. As an alternative strategy for provider payment, they were a key feature of Medicare reforms in the 2010 Affordable Care Act. Since these reforms are relatively recent, however, questions remain about how well they will perform and the extent of their impact. The Alternative Quality Contract— a commercial accountable care organization contract— was shown to reduce spending for the Blue Cross Blue Shield enrollees it covered, as intended, but how did it affect care for other patients of the same practices? Would providers make up for cutting back on the number of procedures performed on patients covered by the AQC by performing more for their non-AQC patients?  The findings suggested much more encouraging responses by providers than that.

 “The spillover savings in Medicare that we found suggest that at least some of the interventions providers adopted in response to the AQC changed the way care was delivered for all patients,” McWilliams said. For example, provider organizations might implement new clinical decision support tools that discourage physicians from ordering popular but medically unnecessary imaging studies, such as MRIs for back pain; such tools could work just as well for patients in or out of the ACO contract. However, spillover was not observed for all outcomes. For example, the quality gains associated with the AQC did not seem to spillover to Medicare, suggesting that only AQC enrollees experience those benefits.

These findings have several implications for payment and delivery system reforms, the researchers said.

On the one hand, the cost-reducing spillover effects suggest that providers who are in a plan like the AQC will be likely to enter similar contracts with additional insurers, where they can be similarly rewarded for the savings and quality improvements achieved for the additional insurers' enrollees. If this occurs, ACO-like payment reforms should continue to spread.

However, cost-reducing spillovers also present a free-riding problem to commercial insurers engaged in ACO contracts, since some of the efficiencies stemming from the AQC will benefit competing insurers.

This dilemma highlights the importance of understanding the system-wide effects of health care reforms.

“Additional efforts such as recent state initiatives to contain spending may be needed to foster multipayer participation in new payment systems,” McWilliams said. “Our study of an early ACO program in Massachusetts suggests the potential for these payment models to drive systemic changes in care delivery.”

This study was supported by grants from the Beeson Career Development Award Program (National Institute on Aging grant K08 AG038354 and the American Federation for Aging Research), the Doris Duke Charitable Foundation (Clinical Scientist Development Award 2010053), the National Institute on Aging (grant PO1 AG032952), and the Commonwealth Fund (grant 20110391).

Landon reports consultancy with Active Networks, Navigenics, Massachusetts Medical Society, United Biosource and Research Triangle Institute. Chernew reports board membership on the Medicare Payment Advisory Commission and the Congressional Budget Office.

 

 

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