Thursday, May 13, 2004

No Wonder Reform Comes so Hard
The posting below on Laparoscopic surgery for colon cancer prompts me to report that Mrs. Wittrup (Marilyn) underwent the same type of surgery last month to repair a torn rotator cuff.

The damage was apparently done some 18 months ago when she fell on some wet leaves and fractured a bone in her arm. The orthopedist who took care of her then was not clever enough to pick up the shoulder problem. When it was diagnosed earlier this year, there was concern that the muscles might have atrophied from disuse, making repair impossible.

But, apparently, she lucked out. The surgeon reports that he was able to accomplish a great deal and that she should recover nearly full use of her shoulder.

The operation was performed using the minimally invasive technique. She was under the knife for nearly two hours (under general anesthesia) beginning at 7:30 in the morning (surgeons being congenitally unable to sleep late). By 6:00 p.m. that same day she was resting in bed at home, about an hour’s drive from the hospital. She had three, one-inch incisions around her shoulder. They have now nearly disappeared.

The orthopedist was personable, attentive, and, according to anything we can learn, highly competent (he does nothing but shoulders). The hospital was organized and its staff members were also attentive and competent. If there were inefficiencies, they were not ones of which a patient would be aware (except that I thought she should have been able to register on line rather than take the time of a registration clerk).

In other words, she had a significant encounter with the health care system and came away pleased with the people who cared for her, mightily impressed with the high technology of which she was the beneficiary, and pleased with the outcome. The procedure was scheduled to suit her convenience. The facilities were modern and attractive.

What with Medicare and a supplemental health insurance policy, what we paid was a pittance.

In other words, she is what all doctors and hospitals hope for – a satisfied patient. Furthermore, her experience is probably pretty common.

No wonder it is so hard to get people excited about reforming the health care system!!!

Tradition and the Hindering of Progress

According to this morning’s Boston Globe, today’s issue of the New England Journal of Medicine reports an extensive study showing that patients having laparoscopic surgery for colon cancer enjoy the same “success” rates as those having their bellies opened up for a full view. (Laparoscopic surgery, sometimes known as “keyhole” or “minimally invasive” has the surgeon operating by inserting instruments through small incisions and operating by looking at a TV monitor.) It seems that there has been a virtual moratorium on laparoscopic surgery for colon cancer since 1994, when spotty evidence was interpreted to show that colon tumors recurred much more often in patients treated with the minimally invasive technique.

Laparoscopic surgery for colon cancer is not appropriate in all cases, such as those in which the cancer has spread to surrounding tissue. But where it is appropriate, and considering its obvious advantages (smaller incisions, less pain, shorter hospitalization, quicker recovery), one would suppose that before many months have passed, it would be universal practice.

Not likely. Learning to do laparoscopic surgery requires intensive training – something not all surgeons will be anxious to undertake. On this point, the Globe article quoted Dr. Philip B. Paty, colorectal surgeon at Memorial Sloan-Kettering Cancer Center in New York as saying “I don’t see an immediate boom.”

What ought to be happening is that by this time a couple of months from now, hospital CEO’s across this land should have presented to their Boards of Trustees specific plans and schedules for implementing these new findings posthaste.

But, of course, that would be seen in most cases as interfering in the practice of medicine and, therefore, inappropriate. So a whole lot of patients will be getting less than the best care and costs will be higher, as well.

Tradition is a wonderful thing, but not when it hinders progress.

Tuesday, May 04, 2004

Unnecessary Cost – Another Example

Friend, one-time business partner, and retired health care consultant Jeff Frommelt provides the below as another example of unnecessary health care cost:

CHICAGO (May 3) - Symptomless ear inflammation that affects more than 2 million American children a year should be handled with "watchful waiting" and no treatment unless it remains for at least three months, new guidelines say.

Sometimes called silent ear infections, the condition that sometimes follows a cold results in an estimated $4 billion in annual medical costs, including drugs and operations to implant ear drainage tubes.
While in some cases treatment is needed, at least 75 percent of cases clear up on their own within three months, according to the guidelines from the American Academy of Pediatrics. They were published Monday in the May edition of the academy's journal, Pediatrics.

The federal Centers for Disease Control and Prevention estimates at least 6 million courses of unnecessary antibiotics are prescribed yearly for the condition, which is known medically as otitis media with effusion, or fluid in the middle ear.

Sometimes the fluid contains bacteria, but the guidelines say antibiotics are not recommended for routine treatment, although in some cases short-term use may produce benefits, especially as a last resort before tube surgery.

Antihistamine and decongestant drugs are sometimes recommended but are useless for the condition and should be avoided, the guidelines say.

Otitis with effusion or fluid can cause temporarily muffled hearing and sometimes result in a delay in learning a language. Hearing tests should be performed if the fluid condition lasts longer than three months, and language tests are recommended if there is evidence of hearing loss or learning problems, the guidelines say.

Surgery, usually implanting ear tubes, should be considered if the condition lasts four months or longer and children show signs of persistent hearing loss, according to the guidelines.

The condition is different from classic ear infections - acute otitis media - that usually cause pain and other symptoms of inflammation and infection. Classic ear infections also do not usually require antibiotics and should be treated with pain medicine, the academy says.

On the Net: Pediatrics: http://www.pediatrics.org

Now the usual question remains: Who will take responsibility for implementing these recommendations?


Sunday, May 02, 2004

More on Hillary’s Piece

As indicated in my “Hillary’s Back” posting, the Senator Clinton article on which it is based was called to my attention by friends Bob Cathcart and the Berggrens (Warren and Gretchen). So before I posted my comments, I asked them to review it for fairness.

Cathcart’s response, laconic as always, was, “Richard, this is a very fair report. Perhaps the Senator is beginning her campaign for President in 2008.”

The Berggrens remarked at greater length:

“We are interested that your response was to the Q & A more than to the article itself. We think what she implied was that a health plan that does all those things (results) would not ordinarily be developed by one person or agency nor could it be encapsulated in the her response to the follow-up question. Some of the points need underlining, as in home-based health care records &/or information technology for our increasingly mobile population (I still can't get my mammograms out of UT Southwestern to be sent to Colorado despite many attempts and offers to cover postage, etc.). Mothers in developing countries have proven very reliable in keeping their children's growth carts; American mothers are apparently not supposed to, if their physicians' behavior is a clue. Senator Clinton also notes how costly needlessly repeated tests can be. In our own and our neighbors' experience, being referred to a specialist may mean that the specialist repeats many of the tests, and, as she points out, often needlessly. More seriously, there is the fact that increasingly our least served members of society are turning to the remaining emergency services that do not turn them away (as in university-affiliated hospitals) despite long waits (up to 14 hours in UT Southwestern). Rarely if ever is there any follow-up possible. Such negligence has led to Colorado's now having immunization rates that rival those of developing countries for lack of coverage. Surely we need senators who will at least raise some questions!”

Anybody else?


Hillary’s Back!

Responding, no doubt, to my recent posting about the lack of a vision for health care, long-time friends Bob Cathcart and Gretchen and Warren Berggren called to my attention Senator Hillary Clinton’s long article in the April 18, 2004 issue of The New York Times Magazine under the title “Now Are We Ready To Talk About Health Care?”

Cathcart was also good enough to send along the follow-up Q&A as it appeared in the April 23, 2004 issue of the NYT.

Senator Clinton does have a vision of a sort. Perhaps the best expression of it came in response to the question “What does your rescue plan look like and how will it be implemented?

Here is what she said: “I am open to a number of plans, as long as the plan addresses the fundamental issues I’ve raised in the article and provides every American with meaningful, affordable health coverage. I believe a proposal to do so would have to improve the quality of care, expand public health and increase preventive services, reduce fragmentation and administrative costs, increase the use of information technology, and make coverage more affordable for individuals and employers alike. It would have to change incentives so that providers and insurers compete on quality and cost, not on who is the best at excluding sick patients. And I believe a fundamental principle for any proposal would be joint responsibility among the employer, the patient, the provider, rather than shifting all the burden to patients alone.”

The Senator is clear about what the results of a “rescue plan” should be, but, to be fair, that is not the question she was asked. A more direct answer would have been “I don’t have a plan” or “I have a plan but I’m not prepared to reveal it.”

In the last paragraph of her article, Senator Clinton says “The present system is unsustainable. The only question is whether we will master the change or it will master us.”

But she doesn’t tell us what the change should be.

So like Diogenes with his lamp looking for an honest man, I with my blog am still looking for a description of the redesigned health care system that addresses the problems of the current one.


Something Good in Denmark?

The Department of Health Policy and Management of the Harvard School of Public Health puts on a brown-bag-lunch Quality of Care Research Seminar every Tuesday during the academic year. I attend whenever I can.

Last week, the speaker was Dr. Jan Mainz, Professor at the University of Southern Denmark and Project Manager of the Danish National Indicator Project.

Dr. Mainz’ project sets national quality standards for the care of various medical conditions, collects data from hospitals throughout Denmark showing their performance against those standards, and publishes the results on a publicly accessible web page. The results are broken down by county (in Denmark, counties operate the health care delivery system) and by individual hospital. But before publication, a committee for each county and for each hospital reviews the data and adds comments as indicated. Where the standards have not been met (which is often the case), the comments explain why and indicate corrective action being taken.

The example Dr. Mainz presented was stroke care. The quality standards included such things as timely radiographic diagnosis and anticoagulant therapy.

The program has not been in operation very long, but so far the indications are that it is stimulating higher levels of conformity with standards.

Although the Danish health care system is publicly operated, the Danes seem even more reluctant than we are to supervise medical practice. The idea behind the National Indicator Project is that public disclosure will put pressure on providers to perform in conformity with standards.

It is an alternative for America to consider, even though it would be more difficult here than in Denmark, which is much smaller (its population is less than that of Massachusetts) and more able to impose reporting requirements on its publicly operated hospitals.

I am told that small versions of such a reporting scheme are being operated in New York State and Pennsylvania, with the public so far showing very little interest.

Perhaps we should get health care insurers in those areas and public interest groups like AARP to promote the idea more actively.


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