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Going to the hospital?By now, most people know that hospitals are dangerous places, filled with medication errors, infections, poor communications and generally bad service.
Going to the hospital? BYOMD
By now, most people know that hospitals are dangerous places, filled with medication errors, infections, poor communications and generally bad service. In case anyone needs to be convinced, the Institute of Medicine has just released a report on medication errors, indicating --among other things-- that the rate of medication error is about 1 per patient per day!
In the A Piece of Mind column in the July 12 JAMA, Dr. Frederick Hecht of San Francisco recounts the story about his daughter's bout with leukemia four years ago and subsequent recovery. The story is about the extra burden of being a physician when a family member is ill --no blissful ignorance and wishful thinking for him.
But as with any true story about illness and hospitalization, there is a subtext of error and danger:
Several days into my daughter's treatment, I observed that one of the pills she was getting had changed, and it didn't match anything she was supposed to be getting in the Physicians' Desk Reference, which I already had at her bedside. It turned out that she was getting cis retinoic acid (Accutane) rather than all trans retinoic acid (ATRA) due to a pharmacy error. An acne medicine had been substituted for a critical chemotherapy treatment.
Maybe this was the hospital's rendition of "live fast, die young, and leave a good looking corpse." Anyway, he continues:
At another point, I noted a potentially life-threatening drug-induced hepatitis, which had been missed on her maintenance chemotherapy laboratory tests.
In other words, his daughter could well have died if she hadn't had her father, the doctor, looking after her.
Don't be lulled into trusting the hospital to take care of you. If you go to the hospital, try your best to take someone who knows what they are doing and isn't afraid to speak up for you. If possible, BYOMD.
posted by David E. Williams at 12:52 PM 0 comments
Thursday, July 20, 2006
Is the MA Health Care Reform Law built on shaky assumptions?
Is the MA Health Care Reform Law built on shaky assumptions?
Along with notification of an 11%+ increase in my firm's health insurance premium, Blue Cross Blue Shield of MA sent along a handy explanation of the Massachusetts Health Care Reform Law. Point #5, "Funding," says in part:
Since Massachusetts already pays at least $1.1 billion to provide health care for the uninsured, the additional funding requirements are expected to be modest. The bill will redirect the existing funds that currently pay for the cost of care, which is often accessed in the emergency room by people who lack insurance [emphasis mine.] In the future these funds will subsidize the cost of insurance, which will enable people to access care in more appropriate settings and establish relationships with PCPs.
Sounds good, but then along comes a new Health Affairs article (What Accounts For Differences In The Use Of Hospital Emergency Departments Across U.S. Communities?), which challenges the conventional wisdom. The abstract confirms that the point above is a common one:
Increases in the number of uninsured people, who lack access to other types of outpatient care, are often cited [as drivers of increased ER use]
But in a comparison of ER use in different cities in the article, we find that uninsured people don't necessarily cause ERs to be crowded:
Despite popular perceptions, communities with the highest levels of ED use did not necessarily have the highest numbers of uninsured, low-income, racial/ethnic minority, or immigrant residents. For example, Cleveland and Boston had the highest ED use levels among the... sites [studied] and some of the lowest uninsurance rates.
The uninsured may seek a greater proportion of their care in the ER (or maybe not) but they tend to avoid the medical system in general. Meanwhile, insured people are at least as likely as the uninsured to use the ER in a given year.
According to the article, a significant driver of ER use is the difficulty in getting an appointment with a physician. Massachusetts (especially Boston) has some of the longest waiting lists to see physicians. Reducing the number of uninsured is likely to make waiting lists longer, as people who previously avoided the medical system now seek the chance to try out their new health insurance. As waiting lists get longer it may push more people into the ER.
That doesn't mean the health care reform bill is a bad idea. It just means that absent other reforms --namely increasing throughput in physicians' offices through the use of smarter scheduling and webVisits-- it will lead to higher costs and lower service levels.
One caveat: The study analyzes the extent to which different factors are correlated with variations across communities, but doesn't focus on what happens when changes --such as the MA reform bill-- are implemented within a community.
posted by David E. Williams at 6:37 AM 1 comments
Wednesday, July 19, 2006
Service, please
Service, please
Industries that traditionally offer lousy service levels are taking lessons --literally-- from the hotel industry. They are learning to treat customers nicely and do the other things we take for granted when we stay at a quality hotel. The Wall St. Journal article (Selling the Special Touch) raised my hopes by mentioning health care as an industry learning lessons from hotels.
A growing number of companies in industries not known for great customer service -- banks, hospitals, law firms and car dealerships, to name a few -- are increasingly seeking help from luxury hotels that pride themselves on service, like the Four Seasons Hotels Inc. and Marriott International Inc.'s Ritz-Carlton hotels.
I eagerly read on, waiting to read about the great transformation of service levels by hospitals or physician groups. Alas, any such mentions were edited out of the article in favor of more compelling examples from car dealers.
There are some examples of good customer service in health care, but most of the improvements are fairly superficial like adding valet parking to a hospital. We'll have to wait awhile before we read about anything truly wonderful.
posted by David E. Williams at 9:56 PM 0 comments
Tuesday, July 18, 2006
How far could you take this?
How far could you take this?
A Wall St. Journal article about 100 calorie packs --a new gimmick from the food companies to help people control the portions they eat-- got me thinking. The article cited a study I read about before, where researchers gave participants the same foods but varied the portion size. Some people got the standard sized portion, others got one 50% bigger, and others got one twice as big. People who got the 50% bigger plate ate 16% more than those with the standard portion, and those with the double size ate 26% more.
Here's my question: How far could that curve be extrapolated? What if portion sized doubled again? Would people still eat more? How about if it were increased by a factor of 5 or 6? When does the gross out factor set in and people refuse to eat at all?
posted by David E. Williams at 6:14 PM 3 comments
Should we share Pfizer’s optimism?
Should we share Pfizer's optimism?
Pfizer's research chief Dr. John LaMattina is optimistic. Bullish, even. Like other big drug companies Pfizer seldom brings to market a meaningful new drug it has discovered and developed itself. With a $7 billion annual R&D budget that's kind of embarrassing. Big pharma companies have been innovative, but mainly on the commercial side --figuring out ingenious ways to keep generics off the market or beat the taxman, for example.
But Dr. LaMattina insists in an interview in today's New York Times that things are about to change for the better. Pfizer has a rich early-stage pipeline and a couple of later stage products it discovered itself. The article hints that this boost in output could be a harbinger for the industry as a whole.
Even on its innovative new products Pfizer is mixing in a few marketing tricks. Take torcetrapib, which can raise HDL (aka "good cholesterol") and possibly prevent heart disease. Pfizer plans to sell the drug only as a combination product with Lipitor, meaning no other statin --including generic simvastatin-- could be used alongside it, andcouldn'tit couldn't be used alone. I don't have the inside story on this decision, but my speculation is that it's an attempt to prop up Lipitor during that drug's last couple of years of patent protection and also a way to punish the companies making generic statins.
posted by David E. Williams at 6:08 PM 1 comments
Monday, July 17, 2006
A union gives up on employment-based health care?
A union gives up on employment-based health care?
I was a little surprised to read the op-ed piece ÂHorse-and-Buggy Health Coverage in todayÂs Wall St. Journal by Andy Stern, president of the Service Employees International Union:
The employer-based system of health coverage is over. This may sound shocking, coming from a union leader whose members bargain constantly with employers for health-care benefits. But the system is collapsing, crushed by out-of-control costs, a revolutionary global economy and masses of uninsured.
Yes it does Âsound shocking. At the end of the piece we read that the union is the biggest health care union in the country (I knew it sounded familiar), and that goes a long way to explaining the opening statement. Because what Stern calls for is a broadening of the funding base for health care so that employers, employees and government are full partners. That means increasing the amount of funding available and maintaining the growth in demand for his unionÂs members. Not exactly a formula for radical reform.
posted by David E. Williams at 10:49 PM 0 comments
Friday, July 14, 2006
Change of Shift is up at Emergiblog
Change of Shift is up at Emergiblog
Change of Shift, a blog carnival featuring posts about nursing, is up at Emergiblog.
posted by David E. Williams at 4:48 PM 0 comments
Making hospitals less like airplanes
Making hospitals less like airplanes
The UK's Medicines and Healthcare Products Regulatory Agency (MHRA) is telling hospitals there's no need for a blanket ban on cellphones. Many of the NHS's regions have bans on all cellphone use, but the MHRA says that if the reason is to avoid interference with equipment, it's only necessary in specific locations such as ICUs.
I'm not a big fan of cellphone use in public spaces. It's often annoying to hear others on the phone at close quarters. And hospitals are noisy enough as it is. But I also dislike bans that are ostensibly based on "safety" or "security" reasons when they are really just done for the convenience or revenue enhancement of the rule maker. If cellphones are banned, let's be honest about the reasons. In general I think it's reasonable to have access to a cell phone in a patient's room. It should just be used with consideration for others.
posted by David E. Williams at 4:37 PM 1 comments
Thursday, July 13, 2006
If it's been three years you probably didn't need it anyway
If it's been three years you probably didn't need it anyway
Waiting for my flight back from London and having a look through the Guardian. The Brits are known for not complaining about long queues, so the following may not be a surprise:
Some NHS patients in England are still waiting up to two years for an
operation, the government admitted yesterday... [H]ospitals are hitting [the]
target for... patients to get a first outpatient appointment within 13 weeks of
being referred by a GP.
But many then have to wait months for diagnostic tests and further
outpatient appointments before they are allowed to join the inpatient queue.
After that, they can wait a further six months for an operation.
Anyone who survives that process may not need the operation anyway.
posted by David E. Williams at 11:43 AM 0 comments
Wednesday, July 12, 2006
Timothy Leary, Dad and me
Timothy Leary, Dad and me
Magic mushrooms are back. Johns Hopkins researchers have just published a study of the effects of psilocybin, citing promising results. From the Wall Street Journal:
In a study that could revive interest in researching the effects of psychedelic drugs, scientists said a substance in certain mushrooms induced powerful, mind-altering experiences among a group of well-educated, middle-age men and women.
...the episodes generally led to positive changes in attitude and behavior among the 36 volunteer participants and... the changes appeared to last at least two months. Participants cited feelings of intense joy, "distance from ordinary reality," and feelings of peace and harmony after taking the drug. Two-thirds described the effects of the drug, called psilocybin, as among the five most meaningful experiences of their lives.
But not everyone had such a good reaction:
[I]n 30% of the cases, the drug provoked harrowing experiences dominated by fear and paranoia. Two participants likened the episodes to being in a war. While these episodes were managed by trained monitors at the sessions where the drugs were taken, researchers cautioned that in less-controlled settings, such responses could trigger panic or other reactions that might put people in danger.
It sure does sound like the kind of results that are likely to get people to start abusing mushrooms, and that's not a particularly good thing.
I have a distant personal connection to this story. My fairly straightlaced father did his PhD in social psychology at Harvard in the early 1960s. His faculty advisor was Timothy Leary --who led experiments with psilocybin and LSD-- until getting fired. (Dad said Leary was a lousy advisor who mainly wanted an excuse to take drugs.)
Anyway, this connection to Leary came in handy as a way to deflect peer pressure to do drugs during my vulnerable teenage years. After all, unlike most of the freaked out, unhip parents of my friends who had no clue about drugs, my dad was able to talk to me about psilocybin and the like in an informed way and let me know why it was a bad idea to play around with.
"Hey, Timothy Leary was my dad's faculty advisor," I used to say. That was considered pretty cool and no one pressured me.
posted by David E. Williams at 6:33 PM 1 comments
Tuesday, July 11, 2006
Six serious injuries and one death
Six serious injuries and one death
TeGenero, a development stage pharmaceutical company you never heard of before their drug trial almost killed six healthy volunteers, has declared bankruptcy.
The unforeseeable adverse reactions caused by TGN1412 in the TGN1412-HV phase 1 trial have made it impossible to attract the investment necessary for the company to continue operations.
posted by David E. Williams at 6:20 PM 0 comments
Cure for cancer don't get no respect no more
Cure for cancer don't get no respect no more
Actually it would. The problem is that companies are charging very high prices for drugs with fairly marginal benefits. The USA Today's top story isn't about terrorism, gas prices, or the All Star game --it's about high prices for cancer drugs. In case the headline Prices soar for cancer drugs isn't clear enough, there's a little table showing that 10 years ago drugs for advanced colorectal cancer cost $500 and the expected survival period was 11 months. Now the cost of drugs is up to $250,000 and survival is 24 months. That's about $20,000 per month --more than society is willing to pay.
Although some companies like Roche are not embarrassed by the high price of such drugs, other companies may decide to be a bit more conservative. There really is room in the market to charge tens or hundreds of thousands for drugs that work really well. And the numbers cited above are just averages. Certain people are living a lot longer because of new drugs that don't work for others.
But industry needs to think of a smarter way to price, like charging a high price but refunding most of it for patients who don't respond well.
posted by David E. Williams at 5:57 PM 0 comments
Grand Rounds is up at Donorcycle
Grand Rounds is up at Donorcycle
Check out Grand Rounds, the best of the week's medical blogging, at Donorcycle.
posted by David E. Williams at 5:53 PM 0 comments
Monday, July 10, 2006
Even more mainstream
Even more mainstream
A couple weeks ago when I wrote, "Adaptive trials move toward the mainstream" I thought I might have been exaggerating. After all, adaptive trials --which let trials change as they move forward-- are still fairly esoteric in the drug world. But maybe I was write. A Wall St. Journal article (FDA Signals It's Open to Drug Trials That Shift Midcourse) indicates that the FDA is serious enough about adaptive trials that it plans to develop regulatory guidance on them. That could still mean such guidance is several years away from publication and acceptance, but it does mean the agency's serious.
The Journal article talks about the complexity of design and need for advanced statistical analyses and safeguards, but doesn't mention Cytel and other firms specifically set up to serve that need.
posted by David E. Williams at 10:32 PM 1 comments
Friday, July 07, 2006
Bedside manner in the Live Free or Die state
Bedside manner in the Live Free or Die state
From the Associated Press:
A judge has ordered the [New Hampshire] state Board of Medicine to stop disciplinary proceedings against a doctor accused of telling a patient she was so obese she might only be attractive to black men and advising another to shoot herself following brain surgery.
A 2001 complaint accused [Dr. Terry] Bennett of telling a woman recovering from brain surgery to buy a pistol and shoot herself to end her suffering. The doctor was also accused of speaking harshly to a woman about how her son might have contracted hepatitis, according to the ruling.
This guy is an extreme version of a fairly common phenomenon: docs who are insensitive and rude to patients. I especially resent it in physicians who are dealing in life and death situations where patients are clinging to their every word, like in the case of my father in-law's oncologist who made a number of insensitive and hurtful comments that were way out of his domain.
The idea behind "patient experience" and quality ratings is to provide prospective patients with information about how well a physician interacts with patients and how good the medical outcomes are. These two things are not completely independent.
In the absence of rich data experience and quality data at the doctor-level it's necessary to resort to other means. "Patient experience" I can assess directly or by speaking with other patients.
Quality is a little harder to judge. For primary care physicians I try to find out from specialists about the quality of the referrals they provide (for example, a pediatric cardiologist I know was very impressed that our pediatrician had identified a minor abnormality and referred the patient on). For specialists, the best way I know is to ask the fellows in the hospital who work with them. They generally know who is under and over-rated.
Of course this kind of technique depends on knowing people in the system, which not everyone does. And it's anecdotal, even in the best case.
I'm guessing from the article that Dr. Bennett is a PCP. He does sound like a jerk (although I don't assume that his comments have been reported accurately). But if specialists told me he was good at diagnosing problems that others miss I wouldn't necessarily rule him out to be my doc.
posted by David E. Williams at 10:13 AM 1 comments
Thursday, July 06, 2006
A little more than they bargained for
A little more than they bargained for
The last of the six "healthy volunteers" who had a near-death experience in a clinical trial in March has been sent home from the hospital. The other five were discharged earlier.
Don't think they'll try that again.
You can read my original post (This gives new meaning to the term 'healthy volunteer) here.
posted by David E. Williams at 3:35 PM 0 comments
Wednesday, July 05, 2006
Another reason not to use Benadryl as a pediatric sleep aid
Another reason not to use Benadryl as a pediatric sleep aid
I ranted before (Off-label and off base) against parents giving kids Benadryl to help them sleep on airplanes. I hate the idea of giving kids drugs they don't need. It's not good for their bodies and it gets kids used to the notion that there's a pill for every ill and lifestyle choice.
Well it turns out there's another reason not to give kids Benadryl as a sleep aid: it doesn't help them sleep. A new study showed Benadryl to be less effective than a placebo. Although the study was small: 22 children receiving Benadryl and 22 receiving a placebo, it was stopped early because the results were considered so clear.
I also learned that parents are routinely giving their kids the stuff for sleep problems at home, not just for the occasional airplane trip. That's really disturbing.
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