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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Another of the highlights of Nance’s book Why Hospitals Should Fly involves the importance of unambiguous communication and the need to seek clarity from others. The line that really caught my attention was, “I know you think you understand what you thought I said, but I’m not sure if you realize that what you heard wasn’t what I meant?”

All too often, in medicine and in life, miscommunications occur. When we say something, it comes from the context in which we are currently thinking. The receiver of the message may interpret the words in some completely different context. This can result in dramatic degrees of miscommunication between health care professionals and between physicians and their patients. These kinds of miscommunications are one element discussed in my book, Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely and Utterly Wrong (www.compartmentsbook.com).

Nance points out that we should listen to people repeat back what they said to us. That’s one helpful approach. Having a buddy come with the patient to record key points is another. Written instructions may be the most valuable way to assure good communication between doctors and patients.

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John-Henry Pfifferling, director of the Center for Professional Well-Being, said I had to read John Nance’s book Why Hospitals Should Fly: The ultimate flight plan to patient safety and quality care (John J Nance, JD, Second River Healthcare Press, Bozeman, MT, 2008). It’s a wonderful book about the need to improve the safety of health care. The incredible safety record of the airline industry is something our medical system can learn from.

One of the highlights of the book referred to video documentation of operating room procedures. The point was, like the airline uses “black boxes” in cockpits, to review the video and identify possible areas for improvement. If any problem occurred, it is even more important to review and learn from the tapes.

Nance predicts one concern about the tapes: how they might be used against the medical system. Nance’s protagonist responds, “What are we doing [in the OR] that we want to hide?”

This is one of the fundamental principles of doctor rating on DrScore.com. Some people ask, “Won’t doctors hate this?” My response is that doctors have nothing to hide when it comes to patient satisfaction. Doctors want to give patients great medical care, and doctors do so day in and day out. Nothing could be better for doctors than for the public to know how happy most patients are with their doctors.

That’s not to say that doctors can’t do an even better job. Of course they can, and they strive to do so. Patient feedback from online doctor rating gives doctors the assessment tool they need so they know where they stand and where they need to direct further effort. While positive feedback is always welcome, feedback that identifies things that can be improved is a special gift.

Patient safety is a critical issue and one for which Why Hospitals Should Fly offers some valuable insight. However, Nance’s book isn’t about how medical care needs to be more like airlines when it comes to customer service. While I’m sure we can learn something from every industry, I’m not sure the airline industry is the best model of customer service to emulate!

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