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Demystifying Medicine One Month at a Time

Category: patient experience (page 1 of 29)

Questioning a Health Care Sacred Cow

If you’ve worked in U.S. health care for any length of time, you’ve no doubt lived through a period of impending ‘inspection’ by the Joint Commission at your hospital or health care organization. Stress levels amongst all staff inevitably rise in the runup.

Everyone needs to look sharp, have their protocols down, and most importantly, where to find organizational policy information if it’s not available by quick memory retrieval.

One of the 800 lb. gorillas of the U.S. health care world, the JC (as it’s known) audits, inspects and accredits nearly twenty-one thousand U.S. health care enterprises.

I was always under the impression that the JC had a complete monopoly in its market–that is, if your health care organization wanted to be accredited (the vital ‘seal of approval’ for your organization’s public relations and safety standards, but also key for reimbursement through CMS) than you had to play ball with them.

In 2012, one of the hospitals at which I worked decided to go in a different direction, choosing instead to work with the accrediting agency DNV, which has its origins in the world of Norwegian shipping. For real. As in, ocean liners need a ton of regulation and safety standards so that they don’t run into each other and sink. We’re always comparing health care to airlines, right? Maybe it’s not such a big stretch after all.

Like most of my physician colleagues who’d lived through years of JC audits, we were a bit flabbergasted: “You mean the JC actually has competition?” As it turns out, the JC only controls a mere 80% of the market. Turns out it’s only a 785 lb. gorilla.

Even though this whole issue is a little bit “inside baseball,” I wrote an essay about it for NPR. My reasoning was that there’s always value in questioning monolithic conformity. And I had been really surprised to learn that there was actually competition to the JC.

Now comes a study in BMJ, led by Harvard researcher Ashish Jha. The study compared more than 4000 U.S. hospitals and the outcomes generated for 15 common medical conditions and six common surgical conditions between the years 2014-2017 in a Medicare population data set of more than four million patients.

What did the study find?

Interestingly, there was no statistical difference in 30-day mortality or readmission rates in the patients that were seen at JC-accredited hospitals vs. those at hospitals accredited by ‘other independent organizations.’ There was a slight but not statistically significant benefit in mortality and readmission rates for JC-accreditation vs. hospitals reviewed and accredited by state survey agencies.

The study raises the reasonable question: if there aren’t patient outcome differences in hospitals accredited by JC vs. those accredited by either state review (government) or other independent agencies (other privates), then should the JC enjoy such a massive industry dominance?

After all–many health care leaders cite the JC’s regulatory and inspection processes as burdensome, and argue that the whole preparation game and citation-fixing business is expensive and distracting from the core hospital mission: taking care of people.

Other JC critics cite the fact that the organization is less than optimally transparent, electing to keep its inspection reports private, despite the fact that many health care enterprises flagged for violations are able to stay accredited.

Congress has even begun an investigation into possible lax oversight.

Apparently Jha’s work has struck a chord, as there was some notable media coverage about the BMJ piece. For one, the Wall Street Journal ran a story about it, which it kept in front of its paywall, while noting that hospitals pay on average $18,000 for an inspection and annual fees of up to $37,000 to the Commission.

Cardiologist and prolific blogger John Mandrola also wrote an opinion piece titled “Joint Commission Accreditation: Mission Not Accomplished.” In his piece, Mandrola compares JC accreditation to medications or surgery that fail to live up to evidence-based standards and subsequently fall out of practice. He concludes, “If the JC’s brand of accreditation can’t show benefit, than it too needs to be de-adopted.”

Having learned that there’s an emerging marketplace of agencies equipped to inspect hospitals and health care enterprises it seems there’s an opportunity here: Perhaps the agency offering the greatest value in terms of cost, reporting, and public accountability will triumph against a behemoth that seems too complacent and entrenched in its ways.

Doximity

Have you heard of Doximity? There’s no reason why you would, unless you’re in the medical world.

Think of it as LinkedIn for doctors and other health care pros. Launched in 2011, Doximity now claims that more than 70% of U.S. physicians are members. If it’s true, that’s a pretty impressive number/captive audience.

They started an authors’ program, where medical pundits offer monthly columns.

My focus has always been on demystifying medicine for non-medical audiences, but I want to see if I can broaden the audience a bit.

My first column was a topic I’ve broached here before: how hospitals go quiet on weekends, which seems nonsensical to me. You can read it here.

The second monthly column just went up; it’s an exploration of why so much dialysis in the U.S. for people with end-stage renal disease (i.e. kidney failure) is of the variety known as “hemodialysis” as opposed to “peritoneal dialysis.” HD mostly involves patients going to centers three times a week for 3-4 hour sessions–which makes maintaining employment darn near impossible.

PD occurs at night, at home, and interestingly it works better (fewer side effects and better longevity) and it’s cheaper overall. So why do only 10% of dialysis patients use it?

In a word, money.

But the good news is that’s changing. Expect to see a significant increase in peritoneal dialysis in the next 5 years–from 10% of patients with end-stage renal disease, to 20% or more. You can read about it here.

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Costs of Care Redux: Extremis Edition

It’s not new to GlassHospital readers, but coverage of outrageous health care bills in the United States is having a bit of a moment.

At least two major news sources, NPR and Vox, are running series in which people who have received bills for health care that seem outrageous can share them with investigative journalists and get help.

Based on the success of her book An American Sickness, doctor/journalist/editor Elisabeth Rosenthal and Kaiser Health News are working with NPR to produce one of these stories for web and radio every month.

Story #1 told of a urine test (screening for drugs) that was billed at $17,850. This is not a joke.

Story #2 compared the difference in price between the same CT scan performed at a hospital vs. a freestanding radiology center. [Hint: hospitals are MUCH more expensive places to get tests done.] The same CT scan of a man’s abdomen performed at a local hospital was billed at thirty-three times the price of the outpatient center.

The most recent story featured a disabled Oklahoma librarian, who had surgery on her arthritic foot. When she had sticker shock at the charge of more than $115,000 for her surgery and three day hospital stay, she did a smart thing and asked for an itemized bill. The most outrageous finding? A charge of $15,076 for four tiny screws implanted in her foot.

The moral of these stories is a) hospitals and laboratories can egregiously mark up their prices, without warning, clarity, or fairness; b) if you are faced with such a bill, you simply MUST ask for an itemized list of charges if you want any hope of contesting them.

If you think charges for actual care can be outrageous, how about being charged for NOT getting care?

Vox tells one woman’s story of fainting, going to a nearby Emergency Department, then declining to be treated. Why did she decline? Fear of an exorbitant bill.

So what happened?

After being given an ice pack and a bandage, she declined treatment, went home, and subsequently received a bill for $5,751.

Minister of Loneliness

U.K. Minister of Loneliness Tracey Crouch

The United Kingdom has appointed a Minister of Loneliness, according to several news reports this month.

In announcing the appointment, British Prime Minister Theresa May said

I want to confront this challenge for our society and for all of us to take action to address the loneliness endured by the elderly, by carers, by those who have lost loved ones — people who have no one to talk to or share their thoughts and experiences with,

As more people live longer than ever, loneliness is compounded by physical infirmities that make social interactions difficult.

As a doctor, I consider loneliness a genuine risk to good health, even if the title of said minister reminded me of Monty Python’s famed “Ministry of Silly Walks.” (Apparently, I was not alone in this thought.)


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