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Demystifying Medicine One Month at a Time

Tag: Doximity

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.

Medical Marijuana: Not Up to the Standard

This year Oklahoma voters made a clear choice to legalize medical marijuana, joining thirty other states that permit cannabis for medicinal use.

Unsurprisingly, immediately in the vote’s aftermath, patients began asking me to ‘prescribe’ medical marijuana licenses, as the new law stipulates users must have as a precondition for legal purchase. The new law does not, however, specify qualifying diagnoses for which medical marijuana might be clinically indicated.

My answer thus far has been, “Not now. Likely never.”

This has not been a popular response. One patient looked at me as if I’d put a lump of coal in his Halloween bag.

I’m not a fan of medical marijuana for several reasons. The main issue is the lack of proven medical efficacy. I know there are thousands of anecdotes from people whose pain or anorexia has been diminished by marijuana–and I’m genuinely glad for them. But I’d like to see better powered controlled trials of cannabis products head-to-head with accepted therapeutic agents. Having the FDA weigh in on marijuana’s safety and efficacy would also go a long way toward legitimizing pot’s medicinal use.

Another major problem is smoking the stuff. If we had proven, standardized dosing of edibles, I’d be more supportive of medicinal use. But smoking anything–tobacco, marijuana, vapor juice–is not a healthy practice, and one I counsel patients to avoid. I hear the arguments about the purity of pot and how it’s ‘more natural’ than manufactured tobacco products. The bottom line is that inhaling burning plant matter into your lungs is a terrible idea–regardless of the herb.

If voters want to legalize marijuana for recreational use, I have no objection–provided we put in place a legal framework to make sure that people don’t get hurt. Standardized dosing and measures to assure product consistency would be integral. And we’d need adequate enforcement to make sure that people aren’t impaired when at work or in other situations in which their marijuana use could jeopardize others.

Putting doctors in the middle of what amounts to a political, legal, social, and economic debate steers the medical profession in a race to the bottom–and let’s face it–our profession has enough problems already without being the gatekeepers of grass.

Remember that marijuana is still scheduled by the Drug Enforcement Administration as a Class I narcotic, defined as having “no accepted medical use and high potential for abuse.” So even though medical weed is now legal in my state, I have no interest in violating or abetting violations of federal law.

In fact, as it turns out, since I work at a university, our legal counsel is of the opinion that no provider in our system shall recommend marijuana, since our institution has numerous federal grants and funding streams and must therefore comply with all federal rules and regulations.

Some have suggested that given our national opioid epidemic, marijuana can serve as a safer alternative for pain control. Since most cannabis is homegrown, and where legalized a tax revenue source–this does make medical marijuana a more appealing alternative to propping up the seemingly ubiquitous heroin/fentanyl drug cartels.

This argument makes pot part of a harm reduction strategy, which I’d be more supportive of if the evidence were stronger.

Right now I see the pot economy as a Wild West with hundreds of entrepreneurs and medical professionals looking to stake claims in this new quasi-legal economy.

Get back to me when we have more state/federal legal congruence and clarity on the stuff’s true medical benefits.

This essay originally appeared as a Doximity Op-(m)ed.

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.

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