Health Care Policy


HMS Scientists Receive NIH Director's Awards

Prizes recognize highly innovative investigative approaches, creative research in biomedical science

Four Harvard Medical School scientists are among 86 recipients nationwide honored by the National Institutes of Health High-Risk, High-Reward Research Program.

Neuroscientist Jeffrey Macklis and geneticist David Sinclair are recipients of the NIH Director’s Pioneer Award, which challenges investigators at all career levels to pursue new research directions and develop high-impact approaches to a broad area of biomedical and behavioral science.

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Healthcare policy researcher Sherri Rose is a recipient of the New Innovator Award, which supports unusually innovative research from early career investigators who are within 10 years of their final degree or clinical residency and have not yet received a research project grant or equivalent NIH grant.

Healthcare policy researcher Zirui Song is a recipient of an Early Independence Award, which provides an opportunity for exceptional junior scientists who have recently received their doctoral degree or completed their medical residency to skip traditional postdoctoral training and move immediately into independent research positions.

The awards recognize unconventional approaches to major challenges in biomedical research and honor exceptionally creative scientists pursuing high-risk, high-impact research. The program accelerates scientific discovery by supporting high-risk research proposals that may not fare well in the traditional peer review process despite their potential to advance the field.

“I continually point to this program as an example of the creative and revolutionary research NIH supports,” said NIH Director Francis Collins. "The quality of the investigators and the impact their research has on the biomedical field is extraordinary."

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Macklis, who is the Max and Anne Wien Professor of Life Sciences in the HMS Department of Stem Cell and Regenerative Biology, HMS professor of neurology at the Massachusetts General Hospital, and a faculty member of the Center for Brain Science at Harvard University, explores how neurons of the cerebral cortex develop and communicate with each other as well as ways to regenerate neurons affected by disease. Specifically, the Macklis laboratory focuses on unraveling the biology and molecular mechanisms of neuronal generation and degeneration and how neurons form their long-distance connections and circuitry. Macklis and his team are particularly interested in the precisely assembled diversity of the neuronal circuitry of the cerebral cortex and how this diversity and precision enables high-level sensation, movement, thought and behavior. Importantly, Macklis and colleagues explore how perturbations in these processes can lead to neurodevelopmental, neurodegenerative, and psychiatric conditions, such as autism spectrum disorders, intellectual disabilities, ALS (Lou Gehrig’s disease) and schizophrenia among others. Macklis’ Pioneer Award work directly investigates the biology and function of the molecular machinery—proteins and RNAs—of the distinct and diverse regions of the neuron known as “growth cones.” Growth cones are hand-like sensing structures at the end of neuronal axons responsible for controlling the assembly of the brain’s exquisitely precise circuitry. Growth cones are critical decision-makers that probe their surroundings to detect signals and determine how, whether and when to form connections—or synapses—with other neurons.

Rose, an associate professor of health care policy at HMS. Her work focuses on developing and integrating innovative statistical approaches to improve public health. Broadly, Rose’s methodological research uses nonparametric machine learning as a way to tease out cause-effect relationships and predict outcomes in health and biomedical data. Within the field of health policy, Rose works on risk adjustment, comparative effectiveness research, and health program impact evaluation. She also co-leads the Health Policy Data Science Lab and coauthored the first book on machine learning for causal inference.

Sinclair is a professor of genetics and co-director of the Paul F. Glenn Center for the Biology of Aging at HMS. He is best known for his work toward unraveling the mechanism of aging and his efforts to develop therapies that prevent cellular degeneration, DNA damage and slow down the process of aging and aging-related disease. The primary focus of Sinclair’s laboratory is understanding the role of sirtuin genes in disease development and aging, with associated interests in chromatin, energy metabolism, mitochondria, learning and memory, neurodegeneration and cancer. Most recently, research led by Sinclair showed that feeding mice a compound known as nicotinamide mononucleotide (NMN) may avert and reverse cellular DNA damage, slowing down aging in mice.

Song is assistant professor of health care policy at HMS and an internal medicine physician at Massachusetts General Hospital. His research occurs at the intersection of medicine and economics. Specifically, Song’s work focuses on strategies to improve the value of health care spending, including changes in provider payment, incentives for quality improvement and financing of insurance markets. The goal of Song’s research is to is to generate rigorous evidence to inform health policies and delivery system reform efforts that can have a positive impact on population health.

The High Risk, High Reward program is part of the NIH Common Fund, which supports a series of exceptionally high-impact programs that cross NIH institutes and centers. Common Fund programs pursue major opportunities and gaps in biomedical research that require trans-NIH collaboration to succeed.

In addition to the Pioneer, Early Independence and New Innovator awards, the program also administers the Transformative Research Awards, which promotes cross-cutting, interdisciplinary approaches and are open to individuals and teams of investigators who propose research that could potentially create or challenge existing paradigms.

For 2017, the NIH is giving 12 Pioneer awards, 55 New Innovator awards, 8 Transformative Research awards, and 11 Early Independence awards.

The 2017 awards, totaling nearly $263 million, represent contributions from the NIH Common Fund; National Institute of General Medical Sciences; National Institute of Mental Health; National Center for Complementary and Integrative Health; and National Institute of Dental and Craniofacial Research.


Sharp Rise in Common Ownership

Study reveals surprising degree of shared investment across health sectors

A new way of measuring the financial links that tie together hospitals, skilled nursing facilities, hospices and home health agencies reveals a surprisingly large—and rapidly growing—degree of consolidation across various sectors of the health care industry.

This trend has important implications not only for the cost and quality of care, but also for antitrust, payment and regulatory policies, according to research by investigators at Harvard Medical School and Vanderbilt University School of Medicine.

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Findings of the study appear in the September issue of Health Affairs.

The researchers’ tally of health care facilities with investment stakes by a common investor showed that nearly half of hospitals have shared ownership with some providers in the postacute care or hospice sectors, with shared ownership rising from 25 percent in 2005 to almost 50 percent in 2015. This is a different picture from what emerges with more traditional measures of ownership linkages, such as colocation or joint membership in a common health system.

“This is a big increase in the concentration of common investment across health care providers in a short period of time,” said study co-author David Grabowski, professor of health care policy at Harvard Medical School. “This raises some really important questions including the impact on competition both within and across sectors, quality of care and cost of care.”

Looking at individual health care providers in a given market, it might look like there are a lot of independent options to choose from, the researchers say.

“However, when you roll up the facilities that share a common dominant investor, there’s suddenly a lot less competition than it appears,” Grabowski added.

Historically, health care facilities were owned by a single entity. A skilled nursing facility would either be independent or part of a chain of nursing homes. In recent years, however, the industry has experienced an influx of commercial corporate investment, leading to more complicated and fragmented ownership structures.

In many cases, a single investor might have a large stake in several health care facilities across various sectors within the same market. The increase in shared investors is not unique to health care, Grabowski noted, as mutual funds, trusts, private investment groups and private investors own greater shares of diverse sectors across the entire economy.

Common Ownership Scrutiny

Common ownership stemming from a shared investor has recently come under scrutiny by antitrust scholars and researchers who study other sectors of the economy, but this is believed to be the first study to analyze investor linkages across various sectors in health care.

Tracking common investors across the spectrum of health care sectors has been challenging, so little has been known about the ownership structures across health care delivery systems and how these links have evolved over time.

In the current study, researchers managed to overcome that hurdle by using data from the Provider Enrollment, Chain, and Ownership System of the Centers for Medicare and Medicaid Services, which allowed them to identify common investor ownership links across sectors within the same geographic markets.

In this study, the authors focused only on shared investors that were health care companies, and not mutual funds, trusts or others. Thus, common investor ties across health care sectors may be even more significant.

“Our measure of common investment captured nuanced relationships beyond formal ownership that have the potential to affect the competitiveness of health care markets,” said lead author Annabelle Fowler, a doctoral candidate in the Harvard PhD program in health policy. The effects of those links, the authors emphasize, ought to be carefully examined.

“To monitor and analyze the impact of investor concentration on health care outcomes and spending, regulatory agencies and researchers will need accurate and up-to-date information to assess common investment within and across health care sectors, alongside formal ownership,” Fowler added. 

Market Integration 

Researchers have studied the impact of more direct forms of market integration. Although it theoretically has the potential to improve coordination of care, research has shown that consolidation tends to increase prices and impact clinical decision making. For example, Grabowski noted, studies have shown that hospitals tend to refer their most profitable patients to nursing homes that they own.

Would the same be true of other institutions sharing common investors? Until researchers are able to answer that question, Grabowski said, it is important to map out the investment ties that bind different sectors of the health care industry together, and to share that information transparently with the public.

“As a consumer, I ask myself if I would want to know if the hospital that was referring me to a particular rehab service after my surgery had investors with a stake in the providers my doctors were recommending.” Grabowski said. “The answer is most definitely yes.”

Other contributors included Haiden Huskamp, professor of health care policy at Harvard Medical School, and David Stevenson, associate professor of health policy, and Robert Gambrel, health policy data analyst, both at Vanderbilt University School of Medicine.

The research was supported by the Agency for Healthcare Research and Quality (Grant No. U19HS024072) and the Hospice of the Valley Foundation. David Grabowski serves as a paid consultant to Precision Health Economics, a health care consulting company, and Med1, a telemedicine company. He also serves on the Scientific Advisory Committee for NaviHealth, a post-acute care service.



A Hard Bargain

Getting patients to shop for health care is a tough sell  

Americans extol price shopping for health care as a prudent idea, yet few actually do it even when given the means to, according to the findings of two separate studies led by investigators at Harvard Medical School.

Results of the two analyses, published in the August issue of Health Affairs, cast doubt on the increasingly popular notion that empowering consumers to price shop could help stem the tide of rising healthcare spending, the research team said.

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“The idea is that if you give consumers good information about prices—and make sure they have ‘skin in the game’ through high deductibles or co-pays—they will choose lower-priced providers and services, and market forces will drive spending and prices down,” said Ateev Mehrotra, a health care economist and physician in the HMS Department of Health Care Policy. “That’s the theory. We wanted to see how it works in reality. Turns out, reality is a bit more complicated than that.”      

One study, which analyzed utilization of a comparison shopping tool by consumers, revealed that few used the tool to choose lower-cost options. Offering the tool resulted in no difference in the net cost of care at the population level.

The other study, a national survey of people’s attitudes toward comparison shopping for health services and their shopping behaviors, showed that while the majority favored price shopping, a mere 3 percent actually compared prices across providers.

Policy makers have shown growing interest in the idea that unleashing the power of market competition through price shopping can rein in rising health care costs. Many policies have been designed to use price shopping as the engine of change, such as insurance policies designed to include high deductibles and large co-pays or mandates in more than half of U.S. states that require insurance companies, providers, and employers to give consumers transparent pricing information so that potential shoppers can compare costs.

Mehrotra, who is an associate professor of health care policy at Harvard Medical School and HMS associate professor of medicine at Beth Israel Deaconess Medical Center, worked with colleagues at Harvard Medical School, the Harvard T.H. Chan School of Public Health and the University of Southern California to conduct a nationwide survey of 3,000 people who had recent out-of-pocket health expenses.

Only 13 percent of respondents had sought information about their expected spending before receiving care, and just 3 percent had compared costs across providers before receiving care. Notably, the research found, the low rates of price shopping do not appear to be driven by opposition to the idea of comparison shopping: The majority of respondents said they believed price shopping for care was important and did not believe that more expensive providers necessarily offered higher quality of care. The most common reason for avoiding price shopping was reluctance to switch physicians, with 77 percent of respondents citing this as a factor.  Additionally, 75 percent of people in the survey said they did not know of a price comparison resource. This is despite many efforts by states to make prices more easily accessible.

Would the situation be different if people were offered a price transparency resource?

Unlikely, according to the results of the second study, which looked at whether access to a price comparison tool could spark change in consumer behavior among a group of California public employees. For that study, Mehrotra teamed up with Sunita Desai, a Marshall J. Seidman Fellow in Health Care Policy at HMS and colleagues at Harvard Medical School, the Harvard Chan School, the Center for Innovation at the California Public Employees’ Retirement System and HealthCore.

The researchers focused on employee spending for a set of services, including lab tests, office visits, and advanced imaging services, that were more “shoppable” on the price comparison tool. A mere 12 percent of employees who were offered the tool used it at least once in the 15 months after it was introduced. Use of the tool did not result in lower overall prices for lab tests or office visits. While patients who shopped were able to purchase less expensive services, overall, so few consumers shopped that access to the tool didn’t make a dent in lowering outpatient spending.

The results echo and expand on an earlier study by the same team published in JAMA last May, which found that access to a similar price transparency tool was not associated with lower health care spending.

Taken together, the researchers said, the results of the two new studies add to growing evidence that it may be more difficult than believed to use “consumerism” to drive down health care costs. The researchers noted that future efforts to encourage price shopping will likely require different benefit designs other than deductibles along with tools that are both easier to use and easier to access.

“Tweaking health plan benefits to give people more incentive to shop for lower-priced care options and making the price comparison tools easier to use might encourage more people to price shop,” said Desai, the lead author of the latter study.

“As it stands now, our findings suggest that the current set of transparency laws and online tools have a limited impact on health care price shopping, and even less impact on overall spending or prices,” Mehrotra said. “The evidence we’ve found doesn’t support the enthusiasm that policy makers have had for these tools.”
The transparency tool study was supported by a grant from the California Public Employees’ Retirement System (CalPERS) to Harvard University. Sunita Desai was also supported by the Marshall J. Seidman Center for Studies in Health Economics and Health Care Policy at Harvard Medical School. David Cowling is an employee of CalPERS, which was both the employer that introduced the price transparency tool and the sponsor of this research.




Deep Dive

Machine learning tools search vast oceans of data for insights on health economics

Video: Katherine J. Igoe

In the vast spectrum of data available to health researchers, policy analysts, economists and clinicians, it can be hard to separate the signal from the noise.

Sherri Rose, HMS associate professor of health care policy, is developing new machine learning tools that she says are bringing “statistical advances for big data and data science to answer critical questions in health economics.” She explains how in this short video.

Instead of telling the machines what to look for and how to find it, machine learning starts by giving the program a goal, then letting the software explore different approaches to analyzing the available data.

These techniques—part of what Rose calls computational health economics—are beginning to show remarkable results: finding better ways to design health insurance plan payment, shifting physician payment incentives to reduce health disparities and even demonstrating that health insurers can use prescription drug utilization data to identify unprofitable enrollees.




Mental Health on the Line

Use of telemedicine for mental health in rural areas on the rise but uneven

Newly published research by Harvard Medical School and the RAND Corporation reveals a dramatic growth in the use of telemedicine for the diagnosis and treatment of mental health disorders in rural areas, but strikingly uneven distribution of services across states.

The results, published in the May issue of Health Affairs, stem from analysis of telemedicine use among Medicare beneficiaries nationwide over 10 years.

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The study shows an average 45 percent jump per year in telemedicine visits between 2004 and 2014, among rural patients, with striking variation across states. Four states had no such visits in 2014, while in nine states, there were more than 25 telemedicine visits per 100 patients with serious mental illness. 

The reasons for the dramatically uneven distribution remain unclear, but the study investigators say state laws that regulate the provision and reimbursement of telemedicine services for mental health appear to play some role.

“Our results highlight the growing importance of telemedicine in the treatment of mental health disorders in rural settings where access to mental health care is often problematic,” said study lead investigator Ateev Mehrotra, associate professor in the Department of Health Care Policy at Harvard Medical School.

Additionally, the researchers pointed out, overall use of telemedicine services across all rural patients with mental health disorders remains extremely low—at 1.5 percent.

Telemedicine has been touted as a way to eliminate barriers to treatment for patients who would normally have no access to specialists. In the area of mental health, the researchers say, telemedicine seems particularly promising as a way to close the access gaps by providing remote video conferencing. Compared with other conditions, mental health disorders may be particularly well suited for telemedicine services as patients often do not need a physical exam.

There is an ongoing debate in Congress about the value of expanding telemedicine coverage for Medicare beneficiaries. Given that Medicare coverage standards often set the tone for services covered under commercial health plans, expanding access to telemedicine for Medicare patients could translate to expanding coverage for privately insured patients as well.
The Congressional Budget Office has called for more research in this area as they deliberate on passing federal legislation to loosen restrictions for telemedicine services.

Some medical groups, including the Department of Veterans Affairs, have widely implemented telemedicine services, but Medicare has much more stringent criteria on which services can be reimbursed and a requirement that mandates that the patient and clinician must live in the same state.

In their analysis, the investigators tracked telemedicine visits among Medicare beneficiaries with mental illness over 10 years.

The number of telemedicine visits increased from 2,365 in 2004 to 87,120 in 2014. An average of 5 out of 100 rural beneficiaries with a mental health condition had a telemedicine visit, and the number was even higher—12 out of 100—for patients with serious mental illnesses, such as bipolar disorder or schizophrenia. The latter group makes up a mere 3 percent of rural Medicare beneficiaries, yet it accounted for more than a third of these telemedicine visits.

The investigators underscore the need to balance under-use with over-use and caution that further research is needed to delineate ways to ensure responsible use of telemedicine for mental health.

"This work provides us with crucial information as we move forward to understand whether the rapid rise in mental telehealth actually translates into better patient outcomes,” said co-investigator Sherri Rose, associate professor of health care policy at Harvard Medical School.

This research was funded by an unrestricted gift to Harvard Medical School by Melvin Hall and CHSi Corporation.

Co-investigators included Haiden Huskamp, Jeffrey Souza, Bruce Landon, MD, Anupam Jena and Alisa Busch, of Harvard Medical School, and Lori Uscher-Pines, of the RAND Corporation.


The Coming Sea Change for Health Care

HMS economists discuss the ACA and what might come next

If what’s past is prologue, the history of the U.S. Affordable Care Act suggests that ongoing efforts at national health care and health insurance reform will continue to be tempestuous.

At a recent Talk@12, two leading researchers on health care cost and quality from the HMS Department of Health Care Policy outlined the intended workings of the ACA, highlighted a few of the many political and legal challenges to the original law and set the scene for current efforts underway on Capitol Hill to repeal, replace or reconfigure the law.

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Joseph Newhouse, the John D. MacArthur Professor of Health Policy and Management at Harvard University, and Michael Chernew, the Leonard D. Schaeffer Professor of Health Care Policy at HMS, were joined on campus by students, faculty and staff from across the HMS community. Their talk was also livestreamed to thousands who logged on in 40 countries, including Algeria, Australia, Italy, Romania and Morocco.

Moderator Gina Vild, associate dean for communications and external relations at HMS, invited Chernew and Newhouse to talk through the complexities and controversies around health care reform. Following brief presentations, Chernew and Newhouse took questions from the audience in the auditorium and from livestream viewers via Twitter.

“Imagine that we have a big bag of money that has to pay for all the health care for everyone,” Chernew said. “That money has to come from somewhere.”

In the United States, health care is funded by the people, either through taxes, insurance premiums, or fees paid for care at the doctor’s office or the hospital, said Chernew, who is also the director of the Healthcare Markets and Regulation (HMR) Lab in the HMS Department of Health Care Policy.

“The fundamental debate we’re having now is about best mix of these forms of payment,” Chernew said.

Should healthy people pay more to offset costs for the chronically ill? Should the wealthy pay more for the care of the poor? Should the young pay more to subsidize and support the old? These tradeoffs are at the heart of the philosophical and political questions that fuel the debate around health care reform, Chernew said.

Newhouse described the ACA’s attempt to find the right payment mix, which included the proposed expansion of Medicaid to any American earning less than 138 percent of the poverty level, new marketplaces for small groups of employees and individuals, subsidies to make purchasing insurance more affordable for low-income earners and tax penalties to discourage people who choose not to purchase insurance.

Ongoing opposition

The ACA faced stiff opposition from the time it became a law, with a series of lawsuits by state governors and by Congress challenging various provisions of the legislation. In one case, the Supreme Court overturned rules in the ACA that would have mandated that states expand Medicaid, allowing states to opt out.  

This ruling, and the subsequent decision of 19 states plus the District of Columbia to opt out were the main reason the estimates for the number of people who would be covered by the ACA were so low, said Newhouse, who is also director of the Harvard Interfaculty Initiative in Health Policy.

Because the ACA was designed to work as a complete package, changes in one aspect of the law have had cascading effects on other aspects. For example, when states chose not to expand Medicaid, the people who ended up purchasing insurance through the individual and small group marketplaces were more likely to be chronically ill than insurers had predicted, which destabilized those markets, Newhouse said. 

Chernew noted that recent Republican proposals for replacing the ACA favor a move toward individuals paying more of their share of the costs, either through higher premiums, higher deductibles or higher fees at the doctor’s office.

This could mean charging people who are chronically ill more than their healthy peers, or raising premiums for older Americans. The reason proponents say this is necessary, Chernew said, is that asking individuals to pay more encourages the fiscal discipline needed to curb spending growth, even though it may cause inequity and suffering.

Many paths to change

Though legislative efforts to repeal or replace the Affordable Care Act seem to have stalled, speakers noted that there were many administrative ways to impact the effectiveness of ACA without action from Congress.

“Simply because they can’t get a bill through Congress doesn’t mean that the ACA will work the way it was intended to,” Chernew said.

A pending lawsuit by the U.S. House of Representatives challenging the legality of the subsidies that help make insurance more affordable for low-income earners could end the use of those subsidies, making it impossible for many low-income individuals to afford marketplace insurance and returning them to the ranks of the uninsured.

While the Obama administration was appealing a lower-court decision that the subsidies were not allowed, the Trump administration could drop the appeal and end the subsidies.

The political fallout from these maneuvers is hard to predict, the speakers said.

For some opponents of federal health care reform efforts, Newhouse noted, the key question is who has the right to decide what’s best for the citizens of the United States.

“One of the fault lines that runs through American history is the role of states versus the role of the federal government,” Newhouse said. “Should voters in Massachusetts have the prerogative to tell the people of Texas that Texans have to take better care of their poor people?”

Seeking new solutions

In addition to the ongoing debate about federalism, there is growing recognition that the best way to find solutions to the complex problems of delivering the best, most efficient health care to the most Americans is not through top-down mandates, but through diverse innovation and experimentation at the point of care.

One of the provisions of the ACA was the creation of the Centers for Medicare and Medicaid Services Innovation Center, which encouraged provider groups to find their own ways of improving care. Instead of telling physician practices how to do a better job of coordinating care for chronically ill patients with multiple illnesses, the new program offered incentives for groups that found their own ways of improving care and saving money.

“We’re at the beginning of that process.” Chernew said, noting that many questions remain unanswered.

What do we do to control the growth of spending? Is investing in preventive care a good way to bring down overall costs? Would single payer be more efficient than a system mediated by insurance companies, or do we need more freedom in the market so competition can drive down costs? Which kind of patients benefit most from coordinated care? Is it worth investing in better information technology? And how are we going to pay for all this?

In order for the next plan to succeed in the long term, policymakers, physicians and citizens will have to answer these questions.  

For now, health care spending continues to grow faster than the economy.

“It’s pretty simple math,” Chernew said. “If health care spending continues to grow faster than GDP, eventually there isn’t enough money to pay for health care and all the other things that we want.”




Marathon Risk for Non-Runners

Having a heart attack near a major race makes for grim survival odds

Lead researcher Anupam Jena discusses the findings. Video: Rick Groleau

People who suffer heart attacks or cardiac arrests in the vicinity of an ongoing major marathon are more likely to die within a month due to delays in transportation to nearby hospitals, according to newly published research from Harvard Medical School.

The delays, the researchers say, likely stem from widespread street closures during major races that can hamper transportation in an emergency.

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Writing in the April 13 issue of the New England Journal of Medicine, the study authors call for citywide strategies that ensure unhampered access for medical crews in a certain radius of major races and other large public gatherings, such as sporting events or parades.

Previous studies have examined death rates among marathon runners to assess the risk of endurance training, but this is believed to be the first study to analyze the impact of such races on those living nearby due to causes that have nothing to do with the physical exertion of running a marathon.

“We have traditionally focused medical preparedness and emergency care availability to address the needs of race runners, but our study suggests that effects of a marathon may spread well beyond the course of the event and affect those who live or happen to be nearby,” said the study’s senior author, Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School.

The investigators examined 10 years’ worth of patient records analyzing death rates among older Americans, 65 years of age and over, within 30 days of having a heart attack or a cardiac arrest near a major marathon across 11 U.S. cities. Researchers compared death rates among patients hospitalized on the day of the race with those hospitalized five weeks prior or five weeks after the race. Additionally, the researchers divided patients by ZIP code, comparing death rates among those living near the marathon and those living in ZIP codes well outside of the event’s radius and unaffected by street closures.

Patients admitted to a hospital on race day were nearly 15 percent more likely to die within a month of suffering a heart attack or cardiac arrest compared with those admitted on a nonmarathon day or in a hospital outside of the marathon’s ZIP code(s).

That spike translated into a nearly 4 percent difference in the number of deaths. In other words, the researchers say, for every 100 patients with heart attack or cardiac arrest, three to four more people died within a month in the group admitted to a hospital on race day if they happened to go to a hospital near the race course.

The research also showed that ambulance transport was delayed by an average of 4.4 minutes on marathon days, 32 percent longer travel time compared with transports not delayed by marathons. Additionally, nearly a quarter of patients in the study got themselves to the hospital without an ambulance. While there is no record of the amount of  time private transportation took, the authors suspected that many such trips would have been slow on marathon days.

While the study findings do not establish cause and effect between street closures and greater mortality, the researchers point out that many studies have shown that even very small delays in getting care could make the difference between life and death.

“When it comes to treating people in the throes of a heart attack, minutes do matter. Heart muscle dies quickly during a heart attack, so current guidelines call for rapid intervention, preferably within an hour or so of diagnosing a heart attack, to salvage cardiac muscle function,” said Jena, who is also a physician at Massachusetts General Hospital.

As runners speed through the streets of the nation’s most popular marathons, traffic around race routes slows to a crawl. Marathon organizers make every effort to ensure safe and smooth passage for runners, but large public gatherings—such as major sporting events, parades or Independence Day fireworks—can cause major traffic snags.

So, the HMS researchers wondered what kind of unintended consequences these sprawling, 26.2-mile events might have on the health of people who live near the race course.

The findings suggest that between three and four preventable deaths likely occur each year among older residents who suffer heart attacks and cardiac arrests during marathons across the eleven cities studied.

“Marathons and other large, popular civic events are an important part of the fabric of life in our big cities, and they bring people a lot of pride and joy,” Jena said. “But the organizers of these events need to take these risks to heart when they are planning their events, and find better ways to make sure that the race’s neighbors are able to receive the lifesaving care that they need quickly.”

The races included in the analysis took place between 2002 and 2012 in Boston, Chicago, Honolulu, Houston, Los Angeles, Minneapolis, New York City, Orlando, Philadelphia, Seattle and Washington, D.C.

To rule out other possible explanations for the spike in mortality, the researchers checked to see whether patients were sent to different hospitals, whether they traveled longer distances, whether out of town spectators or race participants skewed the mix of patients, whether people waited until their conditions were more severe before calling for an ambulance, or whether staffing levels or the type of treatment used on marathon days were different from usual, and they found no evidence to support any of these possibilities.

The researchers say that their findings suggest that citywide strategies for emergency medical preparedness need to do more to account for the risks to nonparticipants whose emergency medical care may be delayed.

“When cities host big marathons, or when people participate in races, they don't think that there might be a chance that a person not taking part in the race could die because of the event,” Jena said. “These findings don’t mean we shouldn't have large public events, but hopefully our research will shine some light on the problem and suggest ways that planners can better provide for the health and safety of the people who live nearby.”

N. Clay Mann, professor in the Department of Pediatrics at the University of Utah School of Medicine and director for research at the Intermountain Injury Control Research Center; Leia N. Wedlund, a student at Harvard University; and Andrew Olenski, a research assistant in the HMS Department of Health Care Policy, were co-authors of this study. 

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01).


Location Matters

Patients at hospital-based primary practices more likely to get unnecessary tests and services 

Patients with common conditions such as back pain, headaches and upper respiratory infections are more likely to receive tests and services of uncertain or little diagnostic or therapeutic benefit—so-called low-value care—when they seek treatment in primary care clinics located at hospitals rather than at community-based primary care clinics, according to a nationwide study led by researchers at Harvard Medical School and the David Geffen School of Medicine at UCLA.

The key factor driving this disparity appears to be clinic location rather than clinic ownership, the research showed. Indeed, aside from referring patients to specialists slightly more often, hospital-owned community clinics delivered care otherwise similar to physician-owned community clinics.

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The study findings, published April 10 in JAMA Internal Medicine, found an overreliance on referrals to specialists, CT scans, MRIs and X-rays in patients treated at hospital-based primary care practices, raising concerns about the value of hospital-based primary care, the research team said.

Overtesting and unnecessary referrals are serious concerns because past research shows that up to one-third of medical care may be wasteful or unnecessary. Unnecessary care can not only fuel higher overall treatment costs and spending but also lead to additional invasive and potentially harmful procedures and, in the case of CT scans and X-ray testing, expose patients to unnecessary radiation, the researchers say.

Insights from the study could help hospital-based practices develop strategies that limit the use of tests and procedures that provide little value for patients while driving up health care costs.

“Hospital-based practices need to be aware of their tendency to overuse certain tests and services of questionable therapeutic value for patients with uncomplicated conditions,” said study senior author Bruce Landon, an HMS professor of health care policy and of medicine at Beth Israel Deaconess Medical Center, where he practices general internal medicine. “That knowledge can help both frontline clinicians and hospital leaderships find ways to eliminate or at least reduce such unnecessary services.”

The researchers say their findings suggest that more immediate access to specialists and the proximity and convenience of imaging services in hospitals may drive physicians in such settings to overuse them.

“An estimated 10 to 30 percent of health care spending in the United States stems from services that provide low-value care,” said first author John Mafi, an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA. “Reducing the use of such services can not only help curb health care costs—and redirect such resources in more meaningful way—but also protect patients from the potentially harmful effects associated with such services.”

Common examples of low-value care include prescribing antibiotics for a patient with the common cold or other viral upper respiratory infection not affected by antibiotics, or sending a patient with uncomplicated back pain or headache for an MRI or a CT scan.

In their analysis, the team compared patient records obtained from two national databases, comprising more than 31,000 patient visits over a 17-year period during which patients sought treatment in hospital-based primary care clinics or community-based clinics for upper respiratory infections, back pain and headaches.

In order to better identify patients for whom the services were likely of low value, the researchers excluded those with more complex symptoms suggestive of a more serious disorder as well as people with underlying disorders and chronic conditions.

Antibiotic prescription rates were similar in community- and hospital-based clinics.

However, hospital-treated patients were referred more often for MRIs and CT scans (8 percent, compared with 6 percent) than community-treated patients, more often for X-ray testing (13 percent, compared with 9 percent) and more often for an evaluation by a specialist (19 percent, compared with 7.6 percent).

Additionally, the patients most likely to receive unnecessary tests and services were those visiting hospital-based primary care clinics but seeing someone other than their usual primary care physician. The finding, the researchers say, highlights the importance of continuity of care and suggests that when patients bounce from physician to physician they may be more likely to be overtested or overtreated.

“Not seeing your regular primary care physician—what we call discontinuity of care—might be a weak spot where low value care can creep in,” Landon said. “The more we know about what situations are most likely to lead to patients’ receiving low-value care, the more we can do to prevent it.”

Co-authors on the study include Christina Wee, HMS associate professor of medicine at Beth Israel Deaconess Medical Center, and Roger Davis, associate professor of medicine (biostatistics) at Beth Israel Deaconess and associate professor of biostatistics at the Harvard T.H. Chan School of Public Health.

This research was supported with funding from the National Institutes of Health (Midcareer Mentorship Award K24DK087932 and Harvard Catalyst National Institutes of Health Award UL1 TR001102).


Under Scrutiny

Hospital patients less likely to die when accreditation surveys are underway

Patients treated at hospitals during unannounced accreditation inspections appear to have a slightly lower risk of dying within 30 days of admission, compared with patients treated in the few weeks before or after such surveys take place, according to a study led by researchers at Harvard Medical School and the Harvard T.H. Chan School of Public Health.  

Notably, the research team said, the effect does not seem to be directly related to any of the factors that inspectors focus on, such as hospital-acquired infections or other aspects of patient safety. Rather, the authors said, overall heightened awareness and increased vigilance by clinicians, as a result of intense observation, may explain the effect. The study findings are published March 20 in JAMA Internal Medicine.

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While the differences in mortality risk were small and dissipated soon after the survey visits were over, according to the researchers, even minuscule drops in mortality can have serious aggregate effects on the U.S. population. The trend underscores an opportunity to further minimize preventable harm and boost patient safety efforts across U.S. hospitals, the researchers wrote in the paper.

“As physicians, we have the health and safety of our patients first and foremost in our minds and in all of our efforts,” said study senior author Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School. “It is critical to understand how clinical decisions get made and what can make them better.”

Medical error is a significant cause of preventable death in U.S. hospitals. To ensure compliance and help hospitals identify gaps in their patient safety and quality of care protocols, the hospital-accrediting body known as the Joint Commission performs unannounced on-site inspections as a core part of their surveillance process.

They happen without warning once every 18 to 36 months across all U.S. hospitals. Teams of inspectors descend on the hospital, observing how rigorously clinicians follow patient safety and care procedures, ranging from hand-washing and medication management to clinical note keeping and myriad other routine and unexpected procedures involved in patient care. Low-performing hospitals face penalties, loss of accreditation and, in extreme cases, even closure.

To measure the impact of hospital inspections on patient outcomes, the researchers analyzed records from Medicare patient admissions at 1,984 surveyed hospitals from 2008 to 2012. The researchers focused on inspection weeks and compared patient outcomes to the three weeks before and the three weeks after the inspection took place.

The researchers found that across all hospitals, patients treated during an inspection week had a 1.5 percent lower risk of dying, on average, within 30 days of admission than patients treated in the three weeks before or after an inspection. 

The decrease was more pronounced at major teaching hospitals, where patients admitted during survey weeks had a nearly 6 percent lower chance of dying in the month following admission than patients admitted in the weeks before or after a survey. The researchers found that the steeper drop in mortality risk at teaching hospitals may stem from these institutions’ having more resources and clinical staff and from the intense preparation they have traditionally invested in accreditation performance.

While the cause of the effect remains unclear, the researchers speculate that improvements may stem from the basic human impulse to perform better when being watched and evaluated. In other words, they wrote, the effect may stem from heightened clinician vigilance during periods of intense observation.

Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena

Jena  talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.

“Our results suggest that heightened focus and attention during periods of intense observation may influence clinical decision making and downstream patient outcomes,” Jena said.

The researchers note that the findings require further analysis to tease out precisely what changes in behavior fueled the decline in mortality.

“Interruptions in clinical care occur frequently. Efforts to minimize distractions and increase clinician focus and attention could have measurable impact on patients,” Jena said.

Finding a way to harness that reaction and the behavioral shifts it precipitates could give patient safety efforts a healthy boost, the researchers said.

“We’ve all seen how traffic slows when drivers see a police officer ahead of them on the road,” said the study’s lead author Michael Barnett, assistant professor of health policy and management at the Harvard Chan School and an HMS instructor of medicine at Brigham and Women’s Hospital. “We believe the same dynamic may be at play here, and physicians and staff find ways to step up the overall quality of care when they know they are being observed.”

While the team found significant decreases in 30-day mortality risk among patients admitted during the inspection week, they didn’t find any evidence that patients were doing better because staff were more focused on the specific things that the inspectors were scrutinizing. For example, there was no difference in the levels of hospital- acquired infections, which might be attributed to changes in hand-washing practices or in other infection-prevention measures while inspectors were present. There were no differences in other patient-safety indicators such as the number of preventable pressure ulcers or the number of nonfatal cardiac arrests. Analysis of the differences between preventable postsurgical complications revealed a small reduction during inspection weeks.

"It's an enormous fire drill for hospitals when the inspectors arrive,” said Jena, who is also a physician at Massachusetts General Hospital. “It was entirely possible that the distraction of a Joint Commission visit could lead to worse patient outcomes, but we found the opposite.”

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01) and the Health Resources and Services Administration (T32-HP10251).


Jena received consulting fees unrelated to this research from Pfizer, Inc., Hill Room Services, Inc., Bristol-Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals and Precision Health Economics.


Get What We Pay For?

For hospitalized patients, spending more on care doesn’t buy better health

Hospitalized patients treated by physicians who order more or more expensive tests and procedures are just as likely to be readmitted or to die as patients treated by doctors who order fewer or less expensive tests, according to research led by Harvard Medical School and the Harvard T.H. Chan School of Public Health.

The study, published in JAMA Internal Medicine on March 13, is believed to be the first to examine the impact of individual physicians’ spending patterns on patient outcomes.

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“If you spend more money on a car or a TV, you tend to get a nicer car or a better TV,” said study senior author Anupam B. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School. “Our findings show that’s not the case when it comes to medical care. Spending more doesn’t always mean you get better health.”

Research on variation in spending and outcomes between geographic regions and between hospitals has produced mixed results, but most evidence suggests that greater spending does not reliably translate into better outcomes.

What has been missing from the picture, the authors said, is how individual physician spending within the same hospital translates into patient health. That insight, the researchers added, is a key piece of the puzzle because individual doctors make most of the clinical decisions that drive spending and affect outcomes. 

“Before now, most of the research and efforts aimed at cutting spending and improving the value of care have been aimed at hospitals, health systems and groups of doctors,” said the lead author Yusuke Tsugawa, a research associate at the Harvard T.H. Chan School of Public Health. “The differences between hospitals and regions are important, but they’re only part of the puzzle. Our findings show how important it is to consider the differences between individual doctors in any effort to improve health care.”

The researchers analyzed outcomes among Medicare fee-for-service patients aged 65 years and older who were hospitalized for a nonelective medical condition and treated by an internist between 2011 and 2014.

Health care spending varied more across individual physicians within a single hospital than across hospitals, even after accounting for differences between hospitals and patient populations, the data showed.

Overall, 8.4 percent of the total variation in health care spending could be explained by differences between individual physicians, compared to 7 percent explained by differences between hospitals.

Next, researchers examined the link between physician spending and patient outcomes.

When they compared lower- and higher-spending physicians, the researchers found no difference in 30-day patient mortality, nor did they see a difference in readmissions, two factors regarded as key measures of quality of care.

Jena, who is also a physician at Massachusetts General Hospital, cautioned that it’s too soon to say whether the results mean that higher-spending physicians could simply spend less with no ill effects for patients.

“Say you have two painters. One usually takes two hours to paint a room, and one takes six hours. You can ask the slow painter to hurry up, but you might end up with a room that’s sloppily painted, or with one of the walls the wrong color,” Jena said. “That’s obviously a situation we want to avoid in health care.”

It could be that some doctors don’t fully consider the costs associated with the tests and procedures they order, Jena said, and so policymakers or insurers could create incentives to curb some of the more wasteful spending. On the other hand, Jena said, some doctors might just be less efficient than others and may need additional resources to arrive at a proper diagnosis or an effective treatment. Whatever the causes of the variation, Jena added, these findings underscore the impact of decisions made by individual doctors on health care spending.

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01) and by the Social Science Research Council and St. Luke’s International University (Tokyo, Japan).

Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena

Jena  talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.