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Posts Tagged ‘health care safety’

Medical safety — when can we be as good as the airlines?.

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Airline safety is remarkable.  USA Today reports that US airlines did not have a single fatality last year, the third year out of the last four with no air travel deaths. And that’s with U.S. carriers flying more than 10 million flights and hauling more than 700 million passengers.

Our automobile transport system isn’t that safe.  And how about our medical system? Sure, many deaths can’t be prevented by medical science, but wouldn’t it be great if we were to read a headline sometime soon that reads, “Medical System Documents a Year with No Preventable Deaths” or “No Wrong Site Surgery in 3 of the Past 4 Years”?

Airlines can do this, as there is a system in place for measuring and reporting.  The American medical non-system doesn’t even have a mechanism in place for assessing how many deaths, wrong site surgeries or other major safety issues occur, much less a system for reporting the number or a systematic approach to achieving 100 percent safety.

We may be heading in that direction, though.  Data collection and dissemination continues to get easier and less expensive.  If we can start a website that lets all patients rate their satisfaction with all doctors, we should be able to create reliable safety reporting system.

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The AMA and 47 state medical societies authored a letter to insurers about the unreliability of “claims-based” doctor ratings. Claims-based studies use the billing information doctors send to insurers to assess the quality of the care that is delivered. The AMA letter cited studies by the RAND Corporation showing the limitations of these studies.

The AMA hasn’t offered a better way to assess the quality of care doctors provide. Measuring the quality of medical services that doctors provide is extremely complicated, especially because we want doctors to tailor treatments to each patients’ specific needs, preferences and desires.

One aspect of medical care that may be most easily measured is patient satisfaction. This is what we measure and report at DrScore.com.

Patients always know how satisfied they were with their experiences, and there’s growing recognition of the value of patient satisfaction measurement. Government reimbursement programs covering health care may soon require patient satisfaction measurement. The medical boards that certify physicians may require doctors to document and report results of patient satisfaction surveys, too.

This is good news for doctors. Doctors give patients great medical care, and open reporting of that quality is bound to help the public see what a good job physicians are doing.

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While drug companies make the innovative products that help improve and save lives, these companies also get a bad rap. Pharmaceutical companies are responsible for modern-day medications that let doctors work miracles. Is there a downside, too?

To understand the industry perspective, I spoke with Lori Reilly, Vice President for Policy and Research at the Pharmaceutical Research and Manufacturers of America (PHRMA) on Getting Better Health Care.

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Avandia, a medicine used to treat diabetes, has been the subject of news and controversy. Concerns have been raised about the drug potentially causing an increased risk of heart attacks compared to other treatment options. An FDA panel reviewed the evidence and voted 20-12 to keep Avandia on the market.

The controversy around Avandia is complicated. Concerns were expressed that the manufacturer may have downplayed or hidden evidence of problems with the drug. But so far, a detailed examination of the evidence didn’t lead the FDA panel to call for sales of the drug to stop.

In some of the latest news about the controversy, a couple of members of the FDA panel that reviewed the drug were found to have been paid in the past for services to the company that makes Avandia or by the company that makes the competing product (Wall Street Journal). I doubt this affected the panel deliberations or decision in any substantive way.

The bottom line is that understanding the safety of drug products is really quite difficult. In the case of Avandia, it’s easy (well, at least relatively easy) to show that the drug helps patients control their sugar level. It’s much harder to know if there’s a small increased risk of heart attacks or how big that small increased risk is. If you are taking Avandia, the best course is probably to speak to your doctor about it.

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An article from June in the Archives of Internal Medicine —  “Physicians’ Views on Defensive Medicine: A National Survey (Tara F. Bishop, MD; Alex D. Federman, MD, MPH; Salomeh Keyhani, MD, MPH)  —  said  doctors report that they over-test because of fears of malpractice.  I find this hard to believe.  If doctors really thought a test didn’t have any possibility of showing a problem, how could malpractice result from not doing the test?

We don’t do MRIs or CTs on our dermatology patients.  Those tests may get ordered in the ER because there is the possibility — albeit perhaps remote —that something serious is going on in the head.

I think what doctors are saying is that they do tests that are highly unlikely to be of value to make sure they don’t get sued for missing a highly unlikely event.  But from the patient’s perspective, shouldn’t they be offered that test even if there is only a small, small chance that a problem will be detected?  Unless the test is more dangerous than what might be found, offering the patient the test may be good medicine, not malpractice avoidance.

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Just finished reading Dubner and Levitt’s book Superfreakonomics. It is an entertaining follow-up to their most excellent first book, Freakonomics. Among the eclectic topics in Superfreakonomics is their work on the quality of emergency room (ER) doctors —finding that the likelihood of surviving a trip to the ER depends less on which doctor a patient sees and far more on other factors including patient demographics and condition.

The great majority of patients survive the ER. Dubner and Levitt report that estimates of doctor quality suggest that the quality of the doctor might affect the low death rates by 10 percent. On the positive side, 10 percent of an already very small number is a small effect indeed, so that even average doctors are doing a very good job. On the “glass is half empty” side, over the thousands of patients seen each year in the ER, the difference in quality will end up in a few lives lost, and each one is significant.

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