Archive for the ‘Donald Berwick’ Category

Medical Waste: Part two

Sunday, April 15th, 2012

this ECG is normal

In my last post, about trying to decrease the incredible expense of US health care, I gave a link to the ideas Dr. Donald Berwick had outlined in the April 11th edition of JAMA. He thinks we could save huge amounts in six areas: failure of care delivery; failure of care coordination; overtreatment; administrative complexity; pricing failures and fraud & abuse.

Now I'd like to look at a few specific examples.

The same JAMA edition had a research article titled "Association of Major and Minor ECG Abnormalities with Coronary Heart Disease Events" It detailed the followup of nearly 2,200 people in my age range and up (they were 70 to 79) who were in the Health, Aging and Body Composition Study. Thirteen percent had electrocardiograms with minor changes when the study started; twenty-three percent had more significant changes. Both kinds of ECG changes were associated with an increased likelihood of having coronary artery disease (CHD) during the subsequent years.

Now ECGs are relatively cheap and can be done in many settings. But the senior author, Dr. Reto Auer, said in an interview for a publication called heartwire "Our data do not permit one to say anything about clinical practice." The article itself concluded, "Whether ECG should be incorporated in routine screening of older adults should be evaluated in randomized, controlled trials."

In the same edition of JAMA a Northwestern University Preventive Medicine professor, Dr. Philip Greenland, commenting on Auer's research, mentioned a 1989 summary of the value of the "resting ECG," which said additional study was needed. Dr.Greenland said the major finding in Auer's work was a relatively new measurement called the net reclassification index (NRI). As opposed to diagnostic studies (e.g., does this patient have heart disease), this study hoped to be prognostic, telling what the chances were of a major heart event occurring in the future to a particular study subject. In this case the NRI helped most in reclassifying people into a lower CHD risk group, not a higher one.

All of that is fascinating and the Auer article is a superb example of carefully performed research. But, my fear is that many physicians won't read the caveats. If you ignore the last paragraph, skip the editorial and never get to "'s" take on the work, you may well decide that every older adult should have an ECG done on a regular basis.

What should we do if your cholesterol is high?

In the same edition of the journal is a pair of short articles deliberately set up to examine a medical controversy, in this case whether a middle-aged man with an elevated cholesterol, but no personal or family history of coronary heart disease should be given statin drugs to lower his cholesterol. This is a new feature of the journal, and the accompanying editorial, with the intriguing title, "The Debut of Dueling Viewpoints," explains this will be a continuing series of discussions and debates.

What a wonderful idea.





The the online publication, actually had a nice summary of the two pieces,

Medical Waste: Part one

Thursday, April 12th, 2012

health care costs are making news and setting records

Whenever I think of medical waste I flash back to the episode (It's in one of my old blog posts) with my Radiation Safety Officer standing on a pile of garbage in a municipal dump in Biloxi, MS, holding a Coke bottle that set off a radiation detector. It had tobacco juice spat by a patient who'd had a thyroid scan.

But that's not what I'm writing about today.

There's a great article in the most recent edition of JAMA with the title "Eliminating Waste in US Health Care."  In July, 2010, Dr. Donald Berwick, the lead author, was appointed by President Obama to serve as the Administrator of the Centers for Medicare and Medicaid Services. This was a "recess appointment" of a Harvard Medical School professor of pediatrics with a Master of Public Policy degree who had previously led the non-profit Institute for Healthcare Improvement. Congress did not confirm Berwick (ah, politics, isn't it wonderful) and he left  the position in December, 2011.

Berwick and a colleague at the RAND Corporation. a non-profit with goals of improving both decision-making and public policy by utilizing research and analysis, start by stating our health care costs are frankly not sustainable and yet are growing with 2020 estimates of 20% of our gross domestic product (GDP).

Between 1980 and 2008, our US health care costs, as a share of GDP grew phenomenally. The Kaiser Foundation has an online comparison of health care expenditures in the US and 14 other OECD countries. We not only spend more on health care, our per person growth rate of this expenditure is among the highest in the developed world. Let's put that into concrete terms. The Kaiser paper shows a graph of total health care spending per person versus gross domestic product per person and locates where 15 of the world's developed countries fall in comparing those two variables.

The dots representing thirteen of the countries form a line with Italy having the last spending and the least average "income" per person and Switzerland having the top amounts of that group in both categories. Then there's Norway and the United States, both well off the line. The average Norwegian income is considerably higher than the US average, but the average amount spend on all their health care is way below the line, while ours is far above that same line.

These were 2008 figures, but the major difference was shown in growth of the total spent on health care per person per year and the source of that money. In Norway's case, the bulk is public spending and in ours it is split between public and private. And our growth in both categories tops the pack.

It's time to look at all the ways to solve the puzzle

Dr. Berkwick's article in JAMA details how much we could potentially save with six strategies to reduce "medical waste." The total is staggering: $3 trillion in Medicare and Medicaid savings and $11 trillion overall by 2020. He contrasts this to the savings proposed in the Affordable Healthcare Act of $670 billion between 2011 and 2019, no paltry sum by any means, but dwarfed by the common sense proposals he makes.

And nobody loses by our taking a very close look at his concepts.