Saturday, January 12, 2013

New York City Hospitals to Tie Doctors’ Performance Pay to Quality Measures -

In a bold experiment in performance pay, complaints from patients at New York City's public hospitals and other measures of their care — like how long before they are discharged and how they fare afterward — will be reflected in doctors' paychecks under a plan being negotiated by the physicians and their hospitals.

The proposal represents a broad national push away from the traditional model of rewarding doctors for the volume of services they order, a system that has been criticized for promoting unnecessary treatment. In the wake of changes laid out in the Affordable Care Act, public and private hospitals are already preparing to have their income tied partly to patient outcomes and cost containment, but the city's plan extends that financial incentive to the front line, the doctors directly responsible for treatment. It also shows how the new law could change longstanding relationships, giving more power to some of the poorest and most vulnerable patients over doctors who run their care.

"I would expect that we're going to see this become more and more prevalent in compensation arrangements," said Alan Aviles, president of the city's Health and Hospitals Corporation, which runs the city's 11 public hospitals and is the country's largest public health system, handling more than 1 million emergency room visits a year.

The corporation's plan would make doctors' raises dependent on their performance on quality measures. The details are being negotiated with the doctors' union, but both sides expect to reach an agreement that incorporates the idea.

Still, doctors are hesitant, saying they could be penalized for conditions they cannot control, including how clean the hospital floors are, the attentiveness of nurses and the availability of beds.

And it is unclear whether performance incentives work in the medical world; studies of similar programs in other countries indicate that doctors learn to manipulate the system.

"The consequences in a complex system like a hospital for giving an incentive for one little piece of behavior are virtually impossible to foresee," said Dr. David U. Himmelstein, professor of public health at the City University of New York and a visiting professor at Harvard Medical School, who has reviewed the literature on performance incentives. "There are ways of gaming it without even outright lying that distort the meaning of the measure."

Over the next few years, the federal government will financially reward or penalize hospitals based on how they perform on benchmarks that are believed to be correlated with better patient outcomes. By aligning doctors' pay to the same benchmarks, city hospitals hope to perform well enough to qualify for federal bonuses.

Under the proposal, bonuses of up to $59 million over the next three years would be distributed to about 3,300 doctors, and would be given to physicians as a group at each hospital, rather than as individuals, so that even the worst doctor would benefit. They would amount to up to 2.5 percent of salaries, which range from about $140,000 for entry-level primary-care physicians to $400,000 for experienced specialists.

Dr. Bruce Siegel, president of the National Association of Public Hospitals and Health Systems and a former head of the hospitals corporation, called the plan "unprecedented for American public hospitals, in terms of scale, in terms of moving us into a new model."

Los Angeles County, which has the nation's second-largest public health system after New York, does not have anything similar, said Dr. Anish Mahajan, director of system planning for the Los Angeles County Department of Health Services. "What an intriguing idea," Dr. Mahajan said. "That's something we would hold out as a potential thing we do in the future."

Administrators at several private New York hospitals said they were considering incorporating the federal benchmarks into their salary structures, but have not yet done so on a significant scale.

The public hospital system has come up with 13 performance indicators. Among them are how well patients say their doctors communicate with them, how many patients with heart failure and pneumonia are readmitted within 30 days, how quickly emergency room patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.

Union officials said they were still fighting for wage increases, in addition to performance bonuses. The union has also proposed expanding the indicators to 20, including measures that would give doctors bonuses for going to community meetings, giving lectures, getting training during work hours, screening patients for obesity and counseling them to stop smoking. It has also proposed excluding some patients — like developmentally disabled patients, homeless people and those who have no place to go — from incentives aimed at reducing the time patients spend in the hospital.

A union official, who spoke on the condition of anonymity so as not to upset negotiations, said doctors considered the proposal demeaning. "To say we'll stick a carrot in front of you and therefore you're going to be a better doctor is a little disingenuous," he said.

In a written statement, Dr. Barry Liebowitz, the president of the union, the Doctors Council S.E.I.U., said it supported performance incentives in theory, if they "will improve patient care." But he called for a team approach and hinted that the union would demand more doctors and support staff.

The traditional physician incentive payments, tied to the income they generate for hospitals, have been roundly blamed in recent years for driving up costs. (The hospitals corporation had not used these incentives but, in some cases, had required doctors' groups to meet minimums for billing.) Studies have found that they can lead to excessive testing and "upcoding," or diagnosing ailments as worse than they really are, to justify more patient treatment and higher payments. Mr. Aviles said the corporation's plan would not tie payment to the volume or intensity of care.

But Dr. Himmelstein said there were still hazards in the city's plan. He said that when primary-care doctors in England were offered bonuses based on quality measures, they met virtually all of them in the first year, suggesting either that quality improved or — the more likely explanation, in his view — "they learned very quickly to teach to the test."

"I think the most interesting finding is, things that were not measured, in a few studies, appeared to have gotten a bit worse," Dr. Himmelstein said. For instance, patients were not as likely to stick with the same doctor, possibly because they were encouraged to see whichever doctor was available — speed was one quality measure — rather than the doctor who might know them best. In another example, while the doctors reported that they had controlled blood pressure in virtually all their patients, a random survey showed no downward trend in blood pressure or strokes.

There could have been any number of ways of outsmarting the system, he said: "If you take blood pressures three times and report the lowest, is that lying or merely tipping the numbers in your favor?"

Dr. Himmelstein also said doctors could try to avoid the sickest and poorest patients, who tend to have the worst outcomes and be the least satisfied. But physicians within the public hospital system have little ability to choose their patients, Mr. Aviles said. He added that he did not expect the doctors to act so cynically because, "in the main, physicians are here because they are attracted to that very mission of serving everybody equally."

Friday, January 11, 2013

Fwd: New York City to Restrict Powerful Prescription Drugs in Public Hospitals’ Emergency Rooms -

Some of the most common and most powerful prescription painkillers on the market will be restricted sharply in the emergency rooms at New York City's 11 public hospitals, Mayor Michael R. Bloomberg said Thursday in an effort to crack down on what he called a citywide and national epidemic of prescription drug abuse.

Under the new city policy, most public hospital patients will no longer be able to get more than three days' worth of narcotic painkillers like Vicodin and Percocet. Long-acting painkillers, including OxyContin, a familiar remedy for chronic backache and arthritis, as well as Fentanyl patches and methadone, will not be dispensed at all. And lost, stolen or destroyed prescriptions will not be refilled.

City officials said the policy was aimed at reducing the growing dependency on painkillers and preventing excess amounts of drugs from being taken out of medicine chests and sold on the street or abused by teenagers and others who want to get high.

"Abuse of prescription painkillers in our city has increased alarmingly," Mr. Bloomberg said in announcing the new policy at Elmhurst Hospital Center, a public hospital in Queens. Over 250,000 New Yorkers over age 12 are abusing prescription painkillers, he said, leading to rising hospital admissions for overdoses and deaths, Medicare fraud by doctors who write false prescriptions and violent crime like "holdups at neighborhood pharmacies."

But some critics said that poor and uninsured patients sometimes used the emergency room as their primary source of medical care. The restrictions, they said, could deprive doctors in the public hospital system — whose mission it is to treat poor people — of the flexibility that they need to respond to patients.

"Here is my problem with legislative medicine," said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians and senior vice chairman of emergency medicine at Lehigh Valley Health Network in Eastern Pennsylvania. "It prevents me from being a professional and using my judgment."

While someone could fake a toothache to get painkillers, he said, another patient might have legitimate pain and not be able to get an appointment at a dental clinic for days. Or, he said, a patient with a hand injury may need more than three days of pain relief until the swelling goes down and an operation could be scheduled.

Dr. Rosenau said that the college of emergency physicians had not developed an official position on the prescribing of painkillers in emergency rooms and that he appreciated Mr. Bloomberg's activism in the face of a serious public health problem. But he said pain clinics in states like Florida and California, states where prescription drug abuse is rampant, as well as the household medicine cabinet, were probably a more common source of unneeded painkillers than emergency rooms.

City health officials said the guidelines would not apply to patients who need prescriptions for cancer pain or palliative care, and drugs would still be available outside the emergency room. They said that in this era of patient-satisfaction surveys, doctors were often afraid to make patients unhappy by refusing drugs when they are requested, and the rules would give those doctors some support when they suspected that a patient might be faking pain to get drugs.

"There will be no chance that the patients who need pain relief will not get pain relief," said Dr. Ross Wilson, senior vice president and chief medical officer of the Health and Hospitals Corporation, which runs the city's public hospitals.

Similar rules have been adopted in Washington State and Utah. Dr. Thomas A. Farley, the city's health commissioner, said opioid painkillers were not much different from highly addictive and more taboo street drugs like heroin. He called them "heroin in pill form."

More than two million prescriptions for opioid painkillers are written in New York City each year, the equivalent of a quarter of the city's population, Dr. Farley said, and about 40,000 New Yorkers are already dependent on painkillers and need treatment. Painkillers were involved in 173 accidental overdose deaths in New York City in 2010, a 30 percent rise from five years earlier.

Officials could not say how many prescriptions were written at emergency rooms. Libby Holman, a spokeswoman for Purdue Pharma, which manufactures OxyContin, declined to comment.

Dr. Farley said the city lacked the regulatory authority to impose the new guidelines on its 50 or so private hospitals. But several private hospitals, including NYU Langone Medical Center in Manhattan and Maimonides Medical Center in Brooklyn, said they would adopt them voluntarily.

Dr. Hillary Cohen, medical director of emergency medicine at Maimonides, said that even now, OxyContin was rarely prescribed in the emergency room.

Fatally Ill, and Making Herself the Lesson -

It was early November when Martha Keochareon called the nursing school at Holyoke Community College, her alma mater. She had a proposal, which she laid out in a voice mail message.

"I have cancer," she said after introducing herself, "and I'm wondering if you'll need somebody to do a case study on, a hospice patient."

Perhaps some nursing students "just want to feel what a tumor feels like," she went on. Or they could learn something about hospice care, which aims to help terminally ill people die comfortably at home.

"Maybe you'll have some ambitious student that wants to do a project," Ms. Keochareon (pronounced CATCH-uron) said after leaving her phone number. "Thank you. Bye."

Kelly Keane, a counselor at the college who received the message, was instantly intrigued. Holyoke's nursing students, like most, learn about cancer from textbooks. They get some experience with acutely ill patients during a rotation on the medical-surgical floor of a hospital. They practice their skills in the college's simulation lab on sophisticated mannequins that can "die" of cancer, heart attacks and other ailments. But Ms. Keochareon, 59, a 1993 graduate of Holyoke's nursing program, was offering students something rare: an opportunity not only to examine her, but also to ask anything they wanted about her experience with cancer and dying.

"She is allowing us into something we wouldn't ever be privy to," Ms. Keane said.

So it was that a few weeks later, two first-year nursing students, Cindy Santiago, 26, and Michelle Elliot, 52, arrived at Ms. Keochareon's tiny house, a few miles from the college. She was bedbound, cared for by a loyal band of relatives, hospice nurses and aides. Both students were anxious.

"Sit on my bed and talk to me," Ms. Keochareon said. The students hesitated, saying they had been taught not to do that, to prevent transmission of germs. What they knew of nursing in hospitals — "I'm here to take your vitals, give you your medicine, O.K., bye," as Ms. Santiago put it — was different, after all.

They had come with a list of questions. Ms. Keochareon was suffering from pancreatic cancer, and they had researched the disease ahead of time. They were particularly curious about why she had survived for so long. She had lived with her illness for more than six years — an extraordinary span for pancreatic cancer, which often kills within months after diagnosis.

Why, the students asked, had she managed to keep eating and keep on weight? What was she taking for the pain? How long had it taken for doctors to give her a diagnosis?

"They ask good questions," Ms. Keochareon said one morning, her lips stained red from the liquid oxycodone she was sipping frequently between doses of other drugs. "I forget half the stuff I learned as a nurse, but I remember everything about pancreatic cancer. Because I'm living it."

For Ms. Keochareon, this was a chance to teach something about the profession she had found late and embraced — she became a nurse at 40, after raising her daughter and working for years on a factory floor.

"When I was a nurse, it seemed like most of the other nurses were never too happy having a student to teach," she said, lying in her bedroom lined with pictures of relatives, friends, and herself in healthier times. "I loved it."

A Last Project

Now, her disease had left her passing the days watching Animal Planet, reading a book about heaven and calling friends — so much that her cordless phone never left her side. She also was planning meticulously for her death, down to the green wool cardigan and embroidered shirt she would be buried in. But Ms. Keochareon wanted more as she prepared to die. The project she envisioned would be not just for students, but also for her — a way to squeeze one more chapter out of life.

Spending time with the dying is not fundamental to nurse training, partly because there are not enough clinical settings to provide the experience. The End-of-Life Nursing Education Consortium, a project of the American Association of Colleges of Nursing, has provided training in palliative care to some 15,000 nurses and nursing instructors around the nation since 2000, focusing not just on pain management but also on how to help terminally ill patients and their families prepare for death.

In addition, some students do rotations with hospice nurses, said Pam Malloy, the project's director. But Ms. Malloy said that nursing schools still do not focus on end-of-life care nearly as much as they should. "We live in a death-denying society, and that includes nursing," she said. "People have begun to understand it's important, but we're nowhere where we need to be at this point."

In their conversations with Ms. Keochareon, the students learned that her symptoms had included a burning sensation after eating, for which doctors prescribed an acid blocker. Then came wrenching abdominal pain, which she said doctors dismissed as psychosomatic. She also developed diabetes, another potential sign of pancreatic cancer, and itchiness, possibly from blocked bile ducts.

In 2006, after she had felt sick for several years, a doctor finally ordered a CT scan, and the cancer was diagnosed. Ms. Keochareon was 53 and working at a hospital in Charleston, S.C. She was told that she would probably die within a year or two.

Ms. Santiago and Ms. Elliot were outraged on her behalf. But they were surprised, they said, to learn that instead of anger or shock, the first emotion that Ms. Keochareon felt after her diagnosis was relief because she finally knew what was wrong with her.

The best advice she could give future nurses, Ms. Keochareon said in her reedy voice, was "to just dig a little deeper — you know?"

Ms. Keochareon — who had several unhappy marriages before finding her current husband, Joe — also offered some personal advice. "Don't yell at each other unless the house is on fire," she told the students.

Perhaps more than anything, the students were learning about the challenge of managing late-stage cancer pain in a patient who had outlived her prognosis. Ms. Keochareon's cancer had spread, and there were tumors in her bones and around her throat. By early December, the pain had grown unbearable; Ms. Keochareon was hospitalized for nearly a week while doctors assessed how to control it.

'Let the Patient Talk'

At her request, the students kept visiting. The sessions provided a brief respite for Ms. Keochareon's caretakers, including Roy Christensen, a cousin who moved back from Texas last year to help, and Peggy Casey, her favorite aunt. Seeing their exhaustion, the students learned another lesson: "The patient isn't Martha per se," Ms. Keane said, "it's the entire family."

At Ms. Keane's urging, the students eventually stopped asking questions and practiced what she called "therapeutic communication" instead.

"The way we've learned in school, and haven't applied enough, is just saying, 'I'm glad to be with you; you must be frustrated; you look uncomfortable,'" Ms. Keane said. "And let the patient just talk and talk and talk, and see where they're at."

On a bright day shortly before Christmas, Ms. Keochareon had less to say than usual as Ms. Santiago perched on her bed.

"You look good," Ms. Santiago said softly after they had chatted for a bit. Ms. Keochareon was clearly in pain; she mustered a brief smile and closed her eyes.

"I'm ready to go," Ms. Keochareon told her, opening her eyes again.

Ms. Santiago paused. "Aw," she said, patting Ms. Keochareon's hand. "Well..."

"Don't feel bad," Ms. Keochareon added.

"I know," Ms. Santiago said, shaking her look of concern into a smile. "I know."

She wept after leaving the room. Her father has prostate cancer that has spread, she said; Ms. Keochareon's declaration had left her thinking about him.

"I kind of wanted to break down," she said. "I know I'm going to get there with my dad eventually."

Ms. Santiago said she was afraid of death. Ms. Elliot, having seen it in her job at a local hospital, was less troubled by it. She is a licensed practical nurse who is pursuing a registered nurse degree to advance her career. Still, Ms. Elliot said that when her 81-year-old mother recently asked if she would accompany her to a funeral home to "pick stuff out and get everything ready," she recoiled.

The new drugs that doctors had prescribed during Ms. Keochareon's hospital stay failed to keep the pain at bay. She was trying another combination when Ms. Santiago visited again, shortly before Christmas, but with little relief. Ms. Santiago watched, arms tightly crossed, as Ms. Keochareon grimaced and moaned.

"In school they always teach us that pain management is the biggest thing — like, you know, we have to treat the pain," Ms. Santiago said. "With her it's like, how do you treat it? Like, you've tried everything. What else is there to try?"

She rubbed an anesthetic gel on Ms. Keochareon's back and, with Ms. Keane's help, tried to position her hospital bed to be more comfortable. Sunlight streamed through the window into the small, warm room; birds flitted around a feeder just outside. Ms. Keochareon briefly felt better and wanted Ms. Santiago to see her portfolio: a binder that contained her résumé, nursing licenses and letters of recommendation.

Learning from books was good, she said; learning from patients was better.

"When you look back," Ms. Keochareon said, "you associate a certain person with a certain diagnosis."

Ms. Santiago planned to return two days later. But Ms. Keochareon seemed to be saying goodbye.

"I'm sorry I went downhill so fast," she said. "I thought I could teach more."

Running Out of Time

Later that afternoon, Mr. Christensen, her cousin, called with an update. Ms. Keochareon had asked for an intravenous sedative that would make her sleep, delivering her from the mounting pain. That morning's visit, it turned out, had been the last.

Ms. Elliot, who had planned to visit Ms. Keochareon after her shift that day, regretted not having asked more about how she felt about death.

"She already seemed to be at that spot where she had that inner peace about it," Ms. Elliot said that evening. "You want to ask them the questions: So what does it feel like to be dying? Do you know something we don't know?"

Ms. Keochareon died nine days later, in the evening on Dec. 29. Mr. Christensen had asked her to wait for snow; nearly six inches fell that night, the first of the season. Only her husband was there for her death — a consequence of the weather, but perhaps also part of her plan, Mr. Christensen said.

At the funeral, Ms. Keochareon's sister Ruth Woodard spoke in her eulogy about "just what prompted Martha to offer her situation up as a teaching tool." Ms. Keochareon deeply wanted nurses to understand her illness from the patient's perspective, she said. But that was not all.

"I notice that every time that Martha gave of herself she received far more," Ms. Woodard said. "In fact, she received a few moments of less pain and I suspect that she received life itself — a few more hours, even days, with purpose."

When the new semester starts this month, Ms. Santiago and Ms. Elliot will return to more conventional coursework: a pharmacology class, for example, and rotations in maternity and acute care. But they will also present to their classmates what they learned in the little house in South Hadley. Ms. Santiago said she would remember Ms. Keochareon "until the day that I die" — especially her resolve.

"Who in her situation, to be like that, would call up and say, 'Hey, I want to teach a student about my cancer?'" she said.

Qualcomm Tricorder X PRIZE | Healthcare in the palm of your hand

Imagine a portable, wireless device in the palm of your hand that monitors and diagnoses your health conditions. That's the technology envisioned by this competition, and it will allow unprecedented access to personal health metrics. The end result: Radical innovation in healthcare that will give individuals far greater choices in when, where, and how they receive care.

The Qualcomm Tricorder X PRIZE is a $10 million global competition to stimulate innovation and integration of precision diagnostic technologies, making reliable health diagnoses available directly to "health consumers" in their homes.

The dire need for improvements in health and healthcare in the U.S. has captured the attention of government, industry, and private citizens for years. But a viable solution has yet evaded one of the most technologically advanced, educated and prosperous nations on the globe. Integrated diagnostic technology, once available on a consumer mobile device that is easy to use, will allow individuals to incorporate health knowledge and decision-making into their daily lives.

Advances in fields such as artificial intelligence, wireless sensing, imaging diagnostics, lab-on-a-chip, and molecular biology will enable better choices in when, where, and how individuals receive care, thus making healthcare more convenient, affordable, and accessible. The winner will be the team whose technology most accurately diagnoses a set of diseases independent of a healthcare professional or facility, and that provides the best consumer user experience with their device.

Electronic Records Systems Have Not Reduced Health Costs, Report Says -

The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.

Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.

"We've not achieved the productivity and quality benefits that are unquestionably there for the taking," said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month's edition of Health Affairs, an academic journal.

RAND's 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner's revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.

"RAND got a lot of attention and a lot of buzz with the original analysis," said Dr. Kellermann, who was not involved in the 2005 study. "The industry quickly embraced it."

But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

Health care spending has risen $800 billion since the first report was issued, according to federal figures. The reasons are many, from the aging of the baby boomer population, to the cost of medical advances, to higher usage of medical services over all.

Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm's acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.

The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. "We could be getting much more if we could take the time to do a little more planning and to set more standards," said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system and is cited by RAND as an example of how the technology can help improve care and reduce costs.

The RAND researchers pointed to a number of other reasons the expected savings had not materialized. The rate of adoption has been slow, they said, and electronic records do not address the fact that doctors and hospitals reap the benefits of high volumes of care.

Many experts say the available systems seem to be aimed more at increasing billing by providers than at improving care or saving money. Federal regulators are investigating whether electronic records make it easier for hospitals and doctors to bill for services they did not provide and whether Medicare and other federal agencies are adequately monitoring the use of electronic records.

Technology "is only a tool," said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. "Like any tool, it can be used well or poorly." While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.

Federal officials say they are drafting new rules to address many of the concerns about the current systems.

A handful of lawsuits have been filed over the systems. In the fall of 2010, for example, Girard Medical Center, a small hospital in Crawford County, Kan., hired Cerner Corporation to install an electronic records system. The hospital was hoping to obtain federal financing for it.

But after receiving $1.3 million in payments, Cerner employees failed to get the system up and running in time for the hospital to qualify for federal incentive payments. The company then notified the hospital that it was abandoning the project, according to a lawsuit Girard filed against Cerner last year. The case is in arbitration. A lawyer for Girard and a spokeswoman for Cerner declined to comment.

Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.

The 2005 RAND report helped Cerner executives and others sell the new systems, despite criticism at the time that the analysis was too rosy. RAND said that the report was not influenced by its financial backers and that, in fact, it disclosed the corporate sponsorship prominently in the report itself.

The study was harshly criticized by the Congressional Budget Office for overstating expected savings.

The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND's health advisory board wanted to revisit the earlier analysis.

Dr. David J. Brailer, who was the nation's first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the "colossal strategic error" that occurred was a result of the Obama administration's incentive program.

"The vast sum of stimulus money flowing into health information technology created a 'race to adopt' mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow," Dr. Brailer said.

Thursday, January 10, 2013

Americans Under 50 Fare Poorly on Health Measures, New Report Says -

Younger Americans die earlier and live in poorer health than their counterparts in other developed countries, with far higher rates of death from guns, car accidents and drug addiction, according to a new analysis of health and longevity in the United States.

Researchers have known for some time that the United States fares poorly in comparison with other rich countries, a trend established in the 1980s. But most studies have focused on older ages, when the majority of people die.

The findings were stark. Deaths before age 50 accounted for about two-thirds of the difference in life expectancy between males in the United States and their counterparts in 16 other developed countries, and about one-third of the difference for females. The countries in the analysis included Canada, Japan, Australia, France, Germany and Spain.

The 378-page study by a panel of experts convened by the Institute of Medicine and the National Research Council is the first to systematically compare death rates and health measures for people of all ages, including American youths. It went further than other studies in documenting the full range of causes of death, from diseases to accidents to violence. It was based on a broad review of mortality and health studies and statistics.

The panel called the pattern of higher rates of disease and shorter lives "the U.S. health disadvantage," and said it was responsible for dragging the country to the bottom in terms of life expectancy over the past 30 years. American men ranked last in life expectancy among the 17 countries in the study, and American women ranked second to last.

"Something fundamental is going wrong," said Dr. Steven Woolf, chairman of the Department of Family Medicine at Virginia Commonwealth University, who led the panel. "This is not the product of a particular administration or political party. Something at the core is causing the U.S. to slip behind these other high-income countries. And it's getting worse."

Car accidents, gun violence and drug overdoses were major contributors to years of life lost by Americans before age 50.

The rate of firearm homicides was 20 times higher in the United States than in the other countries, according to the report, which cited a 2011 study of 23 countries. And though suicide rates were lower in the United States, firearm suicide rates were six times higher.

Sixty-nine percent of all American homicide deaths in 2007 involved firearms, compared with an average of 26 percent in other countries, the study said. "The bottom line is that we are not preventing damaging health behaviors," said Samuel Preston, a demographer and sociologist at the University of Pennsylvania, who was on the panel. "You can blame that on public health officials, or on the health care system. No one understands where responsibility lies."

Panelists were surprised at just how consistently Americans ended up at the bottom of the rankings. The United States had the second-highest death rate from the most common form of heart disease, the kind that causes heart attacks, and the second-highest death rate from lung disease, a legacy of high smoking rates in past decades. American adults also have the highest diabetes rates.

Youths fared no better. The United States has the highest infant mortality rate among these countries, and its young people have the highest rates of sexually transmitted diseasesteen pregnancy and deaths from car crashes. Americans lose more years of life before age 50 to alcohol and drug abuse than people in any of the other countries.

Americans also had the lowest probability over all of surviving to the age of 50. The report's second chapter details health indicators for youths where the United States ranks near or at the bottom. There are so many that the list takes up four pages. Chronic diseases, including heart disease, also played a role for people under 50.

"We expected to see some bad news and some good news," Dr. Woolf said. "But the U.S. ranked near and at the bottom in almost every heath indicator. That stunned us."

There were bright spots. Death rates from cancers that can be detected with tests, like breast cancer, were lower in the United States. Adults had better control over their cholesterol and high blood pressure. And the very oldest Americans — above 75 — tended to outlive their counterparts.

The panel sought to explain the poor performance. It noted the United States has a highly fragmented health care system, with limited primary care resources and a large uninsured population. It has the highest rates of poverty among the countries studied.

Education also played a role. Americans who have not graduated from high school die from diabetes at three times the rate of those with some college, Dr. Woolf said. In the other countries, more generous social safety nets buffer families from the health consequences of poverty, the report said.

Still, even the people most likely to be healthy, like college-educated Americans and those with high incomes, fare worse on many health indicators.

The report also explored less conventional explanations. Could cultural factors like individualism and dislike of government interference play a role? Americans are less likely to wear seat belts and more likely to ride motorcycles without helmets.    

The United States is a bigger, more heterogeneous society with greater levels of economic inequality, and comparing its health outcomes to those in countries like Sweden or France may seem lopsided. But the panelists point out that this country spends more on health care than any other in the survey. And as recently as the 1950s, Americans scored better in life expectancy and disease than many of the other countries in the current study.

Wednesday, January 9, 2013

Gaps Seen in Therapy for Suicidal Teenagers -

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders likedepression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

"I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide," said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. "We simply do not have empirically validated treatments for recurrent suicidal behavior."

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. "But it's telling us we've got a long way to go to do this right," Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children's Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. "I think there might have been some carelessness in the way the treatment was done," Ms. McConnell said, "and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn't taking it regularly."

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls' attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

"But that's just one study, and it's small," said Dr. Brent of the University of Pittsburgh. "We can treat components of the overall problem, but that's about all."

Ms. McConnell said that her daughter's depression had seemed mild and that there was no warning that she would take her life. "I think therapy does help a lot of people, if it's handled right," she said.

Tuesday, January 8, 2013

Calling for later, less-frequent Pap tests | News | National Post

Doctors should stop ordering yearly Pap tests for most women, and routine screening for cervical cancer in younger women should be abandoned altogether, a federal task force is recommending.
For the first time in nearly 20 years, the Canadian Task Force on Preventive Health Care has released an updated guideline for cervical cancer screening that recommends starting screening when women are older, and screening them less often in order to avoid the risks of over-testing.
Published Monday in the Canadian Medical Association Journal, the new guideline recommends that women aged 25 to 69 without symptoms of cervical cancer who are, or who have ever been, sexually active, be screened once every three years with a Pap test, which detects abnormal cells in the cervix.
The 1994 guideline recommended screening every three years, but only after two consecutive normal Pap tests.
The old guideline also recommended Pap smears for women once they turn 18 or become sexually active.
But the task force says that, in women under 25, the risks of screening outweigh any possible benefits.
Nearly half — 42%— of women aged 18 to 19 have reported being screened at least once within the previous three years, the authors write in the Canadian Medical Association Journal. But the incidence of cervical cancer in women under 20 is low (0.2 cases per 100,000), and no deaths from cervical cancer were reported among Canadian women under 20 between 2002 and 2006.
Neither could the task force find any data to support the argument that screening younger women helps prevent deaths from cervical cancer when they're older. The risk of cervical cancer increases after age 25, and peaks in a woman's 50s.
Younger women are more likely to have abnormal Pap results. A substantial proportion will have "false positive" results, leading to unnecessary and invasive treatments for abnormalities that would never progress to cancer — procedures that can cause pain, bleeding and scarring to the cervix that can jeopardize a woman's chances of carrying a future pregnancy.
Over the past 50 years, deaths due to cervical cancer have fallen dramatically, the panel writes. Today, a woman's risk of dying from the disease is 0.2 per cent.
"Cervical cancer was, and still is a horrible disease," said task force member Dr. James Dickinson, chair of the guideline work group. "It spreads right through the whole of a woman's pelvis and causes horrible problems with bowel and bladder. It can be a truly horrible disease," said Dickinson, a professor of family medicine and community health sciences at the University of Calgary.
Without Pap testing, the disease would affect 1.5% of women. "This is probably the most successful screening test that we have available," Dickinson said.
Expert advisory bodies have for several years been recommending doctors do away with annual Pap testing and instead screen every three years. "It's just that (doctors) and women have got into this habit of annual Pap smears, and we'd like to get them out of that habit," he said. "The evidence says that three years is enough to get the benefits."
Some women do need more frequent screening, including those who have HIV or are immune suppressed.
The Canadian Cancer Society currently recommends women have regular Pap tests starting by age 21 if they're sexually active.
The organization says it will consult with cervical cancer screening experts across the country to determine "whether this is something we should consider changing," said Gillian Bromfield, director of cancer control policy. She said most provincial and territorial cancer agencies recommend screening starting at age 21.
Bromfield said women should continue to be screened even if they're no longer sexually active. Women who have been vaccinated with the HPV (human papillomavirus) vaccine also need to be screened because the shots do not protect against all forms of the virus.
In 2012, an estimated 1,350 new cases of cervical cancer were diagnosed in Canada, with about 400 deaths.

Cul de Sac | Comics | ArcaMax Publishing

Monday, January 7, 2013

The last sweet years or bad romance? Handling infidelity in the nursing home | Practical Ethics

Ulf suffers dementia and lives in a nursing home. He often interacts with Lena, who also has dementia. They seek each other out, invite each other to their rooms, hold hands and kiss. They can clearly express what they prefer (or not). The staff think they enjoy life and each other's company. There is just one problem for the happy couple: Ulf is married, and his wife is not happy. She and their children strongly dislikes the relation between Ulf and Lena and asks the staff to keep them apart. They argue that if Ulf had been free of dementia he would not have desired contact with Lena; he might sometimes even be confused and think Lena is his wife.

The situation was posed as a question to the ethics committee of the National Board of Health and Welfare in Sweden, and it recently responded that the staff should not try to interfere in the relationship: the welfare and autonomy of Ulf is prior to the wishes of the family. An earlier question dealt with a somewhat similar case, where the cuckolded wife demanded that her husband be both separated from the other woman and medicated to "dampen" him.The committee found that it would be against the autonomy of the man to be medicated against his will, and the staff did not have a right (legally or morally) to prevent patients from seeing each other.

The interesting question is what to make of romances that come about due to dementia. Are they authentic? How do they relate to the interests expressed earlier in life?

First, it is pretty clear that the patients at least in these cases do have autonomy. They have clear preferences in the present, they do make choices, and likely have capacity to deal with their own lives within the nursing home. However, if a person consistently confuses another one for their spouse it can be argued that they do not have the capacity of making the right choices about their love. Capacity might not be true in all cases, but in the following I will assume the patients have the elements of capacity.

Is a love that come about due to dementia authentic and worth respecting?

One approach would be to ask, since attraction happens due to mechanisms in the brain, why we should think attraction in one brain is any more authentic than attraction in any other brain – demented or not. But typically romantic love is believed to be an expression of a whole person: it is not just the result of a small partner-detection subsystem triggering independently of everything else, but linked to a complex web of personality, past emotions and memories, social ideas, subconscious patterns of attraction and repulsion. The whole person is (ideally) involved on all levels. Somebody getting attracted to another just because of an external or internal stimuli cannot be said to have the same level of authenticity, especially if the target is somebody who they would (given past experience) not be attracted to. A good example is the case where a brain tumor caused a man to develop pedophilia (paper), and where the urges disappeared when the tumor was removed. The desires and behavior was not consistent with his past, or with his moral understanding.

So the question is whether the romantic relations in the above cases are due to the whole person or just a malfunctioning brain. I doubt there is any simple answer. But it is worth considering that at least some people with dementia appear to regress to an earlier age: they retain well-consolidated memories from youth and core personality traits remain, despite the losses in other dimensions. In this case one might argue that attraction might be quite authentic: it is due to the strong core elements of the person, shorn of later complications. In other cases there is personality change that might make the relationship plausible given the current personality but not the past one: it might be authentic in the present but not when considering the entire life of the patient.

If we cannot recall past promises (and cannot avoid forgetting them), we are not morally bound by them. It can be argued that the past, healthy person would not have wished to be unfaithful. They presumably had interests about the shape of their future marital life, traditionally expressed in wedding vows. We should generally respect stated interests of people even when they are no longer capable. However, wedding vows rarely seem to prevent infidelity. People often underestimate how much their personalities, values and preferences are going to change in the future, making their stated commitments a great deal less reliable than they intended. People fall in (and out of) love not just because of their brains but their overall life context. Suffering dementia and living separated from one's spouse in a nursing home is a serious change of life context: it would be strange if people did not react to it, including by changing their relationships. We might not want to be unfaithful due to dementia, but the dementia is a necessary precondition for the unfaithfulness in this case: what we really want is not to get dementia in the first place, since it no doubt is going to cause many other undesirable future behaviors and experiences.

If we are serious about enforcing our earlier commitments we might create advance directives, constraining what our future self can do regardless of what they think (for example, telling the nursing home staff on admission to help maintain one's fidelity). But the thought of being constrained what an earlier self desired – given that we have grown and changed – is often disagreeable, so such directives will likely be rare. It is also debatable to what extent "Ulysses contracts" can be morally or legally binding. While autonomy includes the power to bind oneself to a course of action, it also includes the freedom to change one's mind. The standard problems are compounded here because dementia might weaken the identity link to the future self: they are literally a different person, and the past self cannot morally claim any paternalistic power over them.

We might find it unfortunate that respecting the autonomy and well-being of people may force staff and family to tolerate infidelity. But insofar it is an expression of genuine will and produces genuine happiness, it might still be a gleam of sunlight in the late autumn of life.