Tuesday, September 16, 2003

Making Patients Sicker in the UK

The following response just in from (almost) daughter Katrina Taylor:

Hospitals in the UK as elsewhere I imagine, are also battling with Methicillin Resistant Staphylococcus Aurea (MRSA), which is on the increase.

As articles in the press here (Daily Telegraph Dec, 2002 & March 2003 - among others) have pointed out - in the 5 years from 1993 to 1998 MRSA has gone from being a contributing factor to death in 8% of deaths in 1993 to being a contributing factor in 25% of deaths in 1998.

Personal hygiene of staff and cleanliness (or lack thereof) of hospital facilities are cited as contributing to the rise.

I can recall from my only in-patient experience here (in London England) that it wasn't the cleanliness of the implements used which I questioned - or was even aware of. It was the state of the bathroom. As is common on wards here the bathroom, where there is a bathtub, (no showers) is communal. The maternity ward where I was was no different. A day or so after being delivered (by C-section), I went to have a bath. I could see the ring around the tub so it was obviously not clean. After a little scrounging around I found the cleaning cupboards and supplies & cleaned out the tub and took a bath. Then feeling no pain, I cleaned it again for the next girl and went back to my bed where I stripped the bed and remade it using fresh sheets I found on a trolley in the hall. After 2 days they needed changing. The dust under the bed didn't bother me, I wasn't about to go crawling around under the bed. Of course anyone is medicine is probably cringing right now. But the point is - this wasn't in a third world country nor was it in a poor part of town. It wasn't even unusual, here.

The fact seems to be that there is no working chain of command that has authority or acts with authority to check the most basic of work.
Staff, for whom training surely should have included in whatever language they were trained in basics like: you must wash your hands between each and every patient you see - are needing to be reminded to do so. Cleaning, which has been contracted out to specialist firms, needs to be standardised and regularised and then audited or checked. Including surprise inspections. And firms & individuals need to be held accountable for performance.

And I don't believe you need to pay someone more to do their job correctly whether surgeon or cleaner. They just need to be held accountable in some observable and quantifiable way for doing it properly.

Katrina Taylor/London England
Sept 16 2003

Will California Show the Way Again?

The California legislature has passed a bill requiring companies with 20 or more employees to provide health insurance. At this writing, Gray Davis has not decided whether signing it will help or hurt his attempt to avoid recall.

But if the legislature is now ready to pass it, some governor will be willing to sign it before too long.

It’s about time somebody did this. If we want everybody to have health insurance, and if we want a pluralistic system, then health insurance for the employed population will have to be funded in the private sector. And so long as we insist that everybody who needs care gets it, regardless of ability to pay, then making employer-provided insurance compulsory is the only way to prevent the employers who do provide it from paying for the care of the employees of those who don’t.

Up to now, the cause of the uninsured has not had any champion powerful enough to offset the small business lobby. Apparently the cost of caring for the uninsured has gotten onerous enough in California to stimulate political action.

California made competition in health care legitimate in the early 1980’s. Maybe it will do the same thing for compulsory health insurance now.

If it goes through, it will be a windfall for providers. Most likely they will quickly spend it and drive up costs by an equal amount. That will give the California legislature another opportunity for leadership.

A Word on National Priorities from Bill Robinson

I was intrigued by remarks of the campaigning Dr. Dean last week, who said that our national expenditures each month in Iraq were enough to provide health insurance for every American, and that we are the only industrialized nation in the world without it - followed by such sterling examples as Sweden and Canada. All of which justifies the comment of one of our fellow bloggers, that the pro's have to fix this or amatuers will.

I'm minded of the late Jim Hague's favorite sighing quote, "plus ca change, plus c'est la meme chose"

Monday, September 15, 2003

Making Patients Sicker

The September 11, 2003 issue of The Wall Street Journal carried an article about a “far-reaching prevention effort” by CDC and CMS to prevent surgical infections. It quoted the agencies as saying that between 40% and 60% of surgical infections are preventable if doctors and hospitals follow the rules they have laid out.

It further quotes Peter Houck, leading the program for Medicare, as saying that “surgeons have a tendency to do things their own way – such as placing antibiotics directly into a wound or rubbing the drugs into the cement of a hip joint – despite a lack of evidence such techniques work.” He went on to say that “We may in the future pay them more to practice medicine the way the evidence says they should.”

I was raised to believe that you could count on doctors to do the right thing because they were doctors. Now it seems that they don’t have to do it unless they get paid more.

And besides that, don’t all the Chiefs of Surgery and the hospitals they work in have some responsibility here?

Giving Patients Care They Don’t Want While Rationing What They Do

An article in the September 11, 2003 issue of the Boston Globe reported on the common failure of health care providers to honor “do not resuscitate” orders. It cited various studies indicating that 53% of doctors didn’t know when their patients wanted to avoid cardiopulmonary resuscitation, 59% of patients who didn’t want aggressive measures got care inconsistent with their wishes, and 35% of patients who wanted care focusing on comfort got care contrary to their wishes.

Then three days later, the front page of the Boston Sunday Globe featured an article about a group called the Value, Ethics, and Rationing in Critical Care Task Force that has received a $1.8 million grant from Eli Lilly and Company to study the rationing of ICU care. The article describes the group as “tackling one of medicine’s most pressing problems – the soaring cost of care, how to pay for it, and who should get it.”

Maybe the group ought to be studying why the health care delivery system can’t get its act together enough to not give people care they don’t want so that it wouldn’t be necessary to think about withholding the care they do want.

Tuesday, September 09, 2003

Should the Chief of Endocrinology Be Fired?

The September 2, 2003 issue of the New York Times carried an article by Linda Villarosa about the importance of managing the blood pressure of patients with diabetes. It stated that “Studies show that cardiovascular disease, set off mainly by hypertension, is the leading cause of death among people with diabetes, and two of every three diabetes-related deaths are caused by heart disease or stroke.” It went on to say “Research in the last decade has found that lowering blood pressure in patients with Type 2 diabetes leads to sizeable reductions in death rates.”

The article pointed out that a lot of doctors were still concentrating on blood glucose control at the expense of treating hypertension, even though the National Institutes of Health issued an advisory on the matter 3 years ago and the American Diabetes Association has been pushing the subject for several years. It quoted a Dr. James Galvin III, chairman of the National Diabetes Education Program and president of Morehouse School of Medicine as saying “….we are swimming upstream as we try to change an established culture of treatment.”

There are a lot of big hospitals in New York and most likely every one has a Chief of Endocrinology. One wonders why Ms. Villarosa didn’t call them and ask them what they are doing about it.

If she had, and if it turned out that some Endocrinology Departments were not doing much, why wouldn’t that be reason for the hospital to fire their Chiefs?

Tuesday, September 02, 2003

Health Care Cost and Expenditures – Two Different Things

The following just in from Vin Sahney. Vin is at Henry Ford Health System in Detroit. We worked together for the better part of a decade, during which Vin was the planning and strategy guru there. His reputation as a planner is international.

“I think that we need to differentiate between costs and expenditures. Cost is for a defined service. Expenditure is what an employer or Medicare spends for covered services for its members. One of the problems employers face is that new technology and capabilities increase the cost of providing services. Examples are transplant services, chronic care services such as cholesterol reduction, bariatric surgery, etc.

Medicare faces a different problem. When we keep someone living longer, especially with heroic surgery, the expenditures for Medicare increase dramatically. So I don't believe that expenditures are likely going to decrease.

The total expenditure for health care per capita does not include an adjustment for quality of life. In many ways we are letting people drive a Lincoln or Jaguar instead of a Focus, and this raises the total expenditure.

We need to differentiate the quality of design from quality of conformance. As quality of conformance improves for a given level of quality of design, the cost will decrease. But if we keep on improving the design of the product or services, the cost will increase."

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com