Talking to each other
I'm intrigued by one of Rice Memorial Hospital's latest care improvement projects - a whiteboard in patients' rooms for displaying and communicating vital information during the patient's hospital stay.
It sounds so low-tech and obvious, yet communication is often one of the most difficult things to do well in health care. This is especially the case in hospitals, where the care tends to be more complex and patients and families often must deal with multiple people on the staff. It's easy for miscues to happen - for instance, weaning someone off oxygen too quickly or overlooking the prompt removal of a catheter. Sometimes patients are never even asked about their own goals for their care while in the hospital.
Many hospitals use whiteboards for keeping track of the patient's name, the nurse who's currently on duty, and other basic information. What makes Rice Hospital's new whiteboards different is the level of detail they contain on the daily goals for the patient's care. Is the patient on oxygen? Using a catheter? Receiving intravenous medication? Most of these things need to be discontinued before someone is ready to go home from the hospital. The whiteboard is intended as both a summary and a reminder to help expedite the process.
Goals for each patient will be based on the current best evidence in hospital care. Getting patients out of bed for a daily walk, for instance, has been shown to help with the recovery process, and four walks a day appear to be more beneficial than three.
Patient safety is also at stake. In the past, urinary catheters tended to be left in too long, not necessarily because the patient needed a catheter but because it was more convenient for nurses. This practice has been associated, however, with a higher likelihood of infection. It's hoped that by listing this as a goal for the patient's care and keeping it displayed on the whiteboard, the care team will have a structured way of communicating and ensuring it gets done sooner rather than later.
The team that developed the whiteboards envision them as a tool for other types of communication as well. For instance, there's a space to write down information about safe patient handling. Does the patient need a walker or wheelchair? Someone from X-ray who's bringing the patient downstairs to radiology needs to know this so the patient can be transported safely.
The feature I suspect patients and families will like the most, however, is the space on the whiteboard where they can write down their own questions. In the past, this has been somewhat hit-and-miss. Families can't always be there to talk to the doctor when he or she is making rounds. Sometimes queries need to be referred to someone else, such as a social worker, and can easily be lost in the shuffle. When families are provided with a structured way to ask questions and have them answered, most of them will more than likely appreciate the opportunity, whether they actually use it or not.
The first few whiteboards were installed last week in Rice's women's and children's unit. Eventually there will be one in every patient room.
The hospital plans to track their success through a variety of ways - patient satisfaction surveys, feedback from physicians and staff, data on catheter-associated infection rates, and length of stay.
On the surface, it might sound like no big deal to implement something like this. In reality, it takes months of discussion and planning to figure out how to do it effectively and work out the details. The concept was even brought before the hospital's patient advisory committee to gain a sense of whether the public thought the whiteboards would be useful.
This is just one project, it should be noted, out of many care improvement initiatives that are taking place at Rice Hospital (and many other hospitals) at any given time. People go into the hospital expecting that they or their relative will have a quality experience. What they don't often see is the continual amount of work that takes place behind the scenes to make this happen. To be sure, glitches and complications can occur with any hospital stay. But it's not an accident when everything goes smoothly and the patient goes home feeling it was a good experience in the hospital.
Posted by: Anne Polta on February 08, 2010 at 2:42 PM | Comments (0) | Permalink
Tags: hospitals, quality care
When information becomes TMI
At one time, the metrics of health care information were way out of balance. Health care professionals possessed knowledge; most laypersons did not. These days, patients are much more informed than they used to be and they have many more sources to which they can go for information. But there's still one gray zone that hasn't been clearly defined: the zone where being well informed crosses the line into Too Much Information.
It's one of the questions triggered last week by a compelling New York Times series on errors and overdoses in radiation therapy. Readers wondered: Is there a benefit in having patients know this form of cancer treatment can sometimes go horribly wrong? Or would this unduly frighten people? Would they in fact be better off not knowing?
"My 78-year-old mother was just diagnosed with breast cancer and will be having radiation in a few weeks. Now on top of that I'm terrified she's going to be overradiated," one person wrote in the online comment section. "I live on the other end of the state and can't be there with her for her treatment for financial reasons. I don't want her to read this, she doesn't need more worry. What are we supposed to do with this info?"
There's a ton of research examining patients' preferences for doctor-patient communication, decision-making and modes of education. The main lessons that can be gleaned from study after study after study are 1) people's preferences are individual; 2) satisfaction is higher when patients receive the amount of information that's right for them and in the format they prefer; and 3) more information/education, rather than less, tends to lead to better outcomes.
I'll say right up front that I'm strongly biased in favor of being informed. The more you know, the better your ability to understand what's happening, ask the right questions and navigate the health care system more effectively.
But is this always the right route to take? As health information has become more available on the Internet, many doctors report encountering patients who become unnecessarily frightened by what they read online. Sometimes these people misdiagnose themselves or want expensive and inappropriate testing. Often they're simply overwhelmed by the sheer volume of information.
Knowing when enough is enough gets even more difficult when it comes to information that might be distressing for patients to know. As a society, we value patient autonomy and the right to informed consent, yet these boundaries are frequently fuzzy. An article that appeared a couple of years ago in the Journal of Clinical Oncology asks the question: "Is lying less stressful than telling the truth?" The authors note that it's still common for physicians to not be frank about the prognosis for patients who have cancer- and that sometimes this is motivated by the physician's own stress at breaking bad news. Families can be complicit as well in their desire to protect a loved one from too much information.
On some level it's paternalistic to decide on someone else's behalf how much information he or she is capable of handling. On the other hand, there may be times when ignorance truly is bliss. Who's to say where the line should be drawn? It's a thorny issue with no easy or abvious answers.
Photo: Wikimedia Commons
Posted by: Anne Polta on February 05, 2010 at 3:19 PM | Comments (0) | Permalink
Tags: health education, patients
Linkworthy 2.1: In the first person
Sometimes the blogosphere is seen as a sea of dreck. But there are also some wonderful real-life stories to be found - worthwhile writing that illuminates a slice of the human experience and causes us to stop, read and reflect. Today's edition of Linkworthy features a collection of recent personal stories and essays that fall into this category.
If you haven't been following Dana Jennings's blog series about his encounter with prostate cancer, this is a good time to get on board. His latest entry: "Living in the Post-Cancer Moment." He writes, "Post-cancer, more than ever, I am stung by the fact that I am here, that I am this I, this improbable soul." Entries in the rest of the series, which appears in the New York Times, can be found here.
From earthquake-stricken Haiti, via Boston hospital CEO Paul Levy's blog, comes this story of "Bearing Witness to Haiti." It's written by Jeff Swartz, CEO of Timberland, who flew on board a company plane to bring supplies and help. Here's how he describes the aerial view as he arrives:
And in minutes, Port au Prince looms ahead, dense, destroyed, honestly not to be believed, from the air. A densely packed city, an up and down city of folded hills, and everywhere you can see... cataclysm.
... I can't believe the physical destruction. Nor the swarm of humans walking. People walking in the streets - this is one of the overwhelming images of this voyage. Where are they going? What are they seeking? Walking, everywhere. Streets choked with dust and detritus and despair, and folks out walking. Whole blocks just leveled.
Levy shares another story as well, about a 7-week-old baby girl who was pulled alive from the rubble of her home.
What is it like to raise a child with special needs? John Elder Robison has Asperger's syndrome, a form of autism, and is a writer and speaker on autism. He recently completed the foreword to a new book, a collection of essays by parents of special-needs children, and he has shared the foreword on his blog. An excerpt:
With all the names I was called growing up, it's no surprise I saw myself as a misfit child. With that self-image, I naturally thought anyone like me must be a misfit, too. However, I know different now. Today I realize that the autistic condition is really the human condition. Our hopes, dreams and feelings are exactly the same as anyone else's. We just don't show our feelings in the conventional way, and we don't respond to other people's signals as expected.
If you're interested in the book, the title is "Gravity Pulls You In: Perspectives on Parenting Children on the Autism Spectrum." It'll be released soon.
My favorite three entries this week are each a variation on a theme: reacting to the death of a patient. Dr. Rob Lamberts muses about a special patient and why his death was inspiring rather than sad. He explains, "Sometimes it's an honor to be their doctor. We don't always stand against death, sometimes we get to stand with the dying."
The anonymous OncRN has her own special story to share, about missing a longtime patient who unexpectedly died. In a post titled "looking," she writes: "when it's five o'clock on friday and you see the doctor you work with is calling your cell phone, your heart skips a beat. all you know for sure is he's not calling to wish you a happy weekend. you know someone died or is dying but, him? oh please, don't tell me that... not him."
Finally, here's Dr. Aidan Charles with a graceful and contemplative essay about attending a patient's funeral. The opening few sentences:
On the way to the funeral you wonder how you'll be received by the grieving. Although you are confident that your care for the deceased was sincere, professional, and adept, you still question if others will so assume. There is silence in the car. This is a trip you make alone.
Go there and read the rest.
Photo: Wikimedia Commons
Posted by: Anne Polta on February 03, 2010 at 11:47 AM | Comments (0) | Permalink
Tags: linkfest
Rock stars and publicity hounds
Turn on CNN and you're likely to see Dr. Sanjay Gupta reporting on his latest experiences in Haiti and even bandaging injured kids while the cameras roll. Physician superstars such as Andrew Weil, Deepak Chopra and Mehmet Oz are almost household names. On the talk shows and in my own e-mail inbox, doctors flog their latest book or hawk their personal brand of energy bars, anti-aging moisturizer or what have you.
Are we talking about physicians here, or are we talking about celebrity salespeople? It's a somewhat disturbing phenomenon that is becoming the focus of increasing attention, not to mention some criticism.
In one of the latest developments, the Food and Drug Administration cracked down on a cosmetic doctor for pitching an as-yet-unapproved antiwrinkle drug:
The FDA recently sent a warning letter to Dr. Leslie Baumann, a well-known dermatologist and clinical researcher in Miami Beach, citing the doctor for expressing premature enthusiasm in the media for Dysport, an injectable antiwrinkle drug the agency has not yet approved.
Dr. Baumann's comments in the media in 2007 violated restrictions on drug promotion, according to the letter; the agency asked Baumann to explain how she intended to prevent similar violations in the future.
Under the Obama administration, the FDA has stepped up scrutiny of drug advertising, dispatching many warning letters about misleading commercials and online marketing efforts. But this is believed to be the first time the agency has warned an individual investigator - a medical researcher who oversees a clinical trial - for apparently promoting an unapproved drug.
News footage of physician-correspondents in Haiti who have been inserting themselves into the story was the subject of a sharp critique recently at professor Gary Schwitzer's HealthNews Review blog. Schwitzer asks: "Is this a journalist with loyalties to journalism principles? Or is this a physician with loyalties to his/her medical professional oath? It is difficult to be both." He also sought comment from other ethicists, who characterized some of the coverage as exploitive and self-promoting.
As if this weren't enough, physician-blogger Toni Brayer took aim at a celebrity doctor with a recent post titled "Why I Am So Over Dr. Oz." She writes:
When he was first seen on Oprah, he seemed engaging and answered some interesting questions in a real and professional way. The audience loved his blue scrubs and boyish clean-cut open style.
That was then.
Let's face it... the media spotlight seems to corrupt even the best physicians. Dr. Oz now has his own show and website and production company.
It isn't necessarily wrong for physicians to want to hustle a buck. After all, the American economy was built on self-promotion and making money. There's a long tradition in medicine of snake-oil shows; Web sites, media appearances and ties to pharmaceutical companies are simply the latest chapter in the story.
Even when doctors are well-intentioned, however, it's a few short steps over the line from healing into hucksterism. Is the public able to tell the difference? Perhaps they just assume, incorrectly, that a medical degree grants instant credibility.
We'd all do well to remain a little skeptical. Yes, there are times when the celebrity doctors/news correspondents/authors can provide information and insight that's helpful to the public. But sometimes, underneath all the telegenic veneer, what they're really selling is themselves.
Image courtesy of the U.S. National Library of Medicine
Posted by: Anne Polta on February 02, 2010 at 11:58 AM | Comments (0) | Permalink
Tags: health care ethics
Left in the Medicare lurch
Got Medicare? If you do, there's an increasing likelihood in some parts of the United States that you might have to look long and hard to find a doctor who will see you.
Anecdotal evidence has been mounting over the past several months that growing numbers of physicians are opting out of Medicare. One of the latest, and more high-profile, cases: the Mayo Clinic, which stopped accepting Medicare patients at its Glendale, Ariz., clinic as of Jan. 1. Patients who want to continue seeing their doctor can do so, but they'll have to pay cash, plus they'll be assessed an annual $250 administrative fee.
Bloomberg News explains the reason for Mayo's decision:
The Mayo organization had 3,700 staff physicians and scientists and treated 526,000 patients in 2008. It lost $840 million last year on Medicare, the government's health program for the disabled and those 65 and older, Mayo spokeswoman Lynn Closway said.
Mayo's hospital and four clinics in Arizona, including the Glendale facility, lost $120 million on Medicare patients last year, [Mayo spokesman Michael] Yardley said.
There's some concern this might be only the beginning:
Mayo's decision may herald similar moves by other Phoenix-area doctors who cite inadequate Medicare fees as a reason to curtail treatment of the elderly, said John Rivers, chief executive of the Phoenix-based Arizona Hospital and Healthcare Association.
"We've got doctors who are saying we are not going to deal with Medicare patients in the hospital" because they consider the fees too low, Rivers said. "Or they are saying we are not going to take new ones in our practice."
Just to be clear, I've heard no hints or suggestions that medical providers here in west central Minnesota plan to follow suit. And the trend might not be particularly widespread; research by the Center for Studying Health System Change found that 74 percent of the physicians who were surveyed were still accepting most or all new Medicare patients in 2008.
Still, it's troubling. These survey numbers are a year old, and the rumblings of dissatisfaction by physicians are getting louder. On many levels it's hard to blame them. Medicare has tended to respond to escalating costs by simply paying less to the doctors and hospitals who provide the care (a practice, it should be noted, that isn't necessarily confined to Medicare or Medicaid). This kind of math can't and won't work, not in the long term. It's especially onerous for smaller medical practices - and indeed, larger practices and practices with a higher patient volume appear to be the most likely to continue accepting Medicare, an analysis by the U.S. Census Bureau found last fall.
What does it mean for patients? Dr. Marc Siegel, a New York internist, writes about what he has been experiencing:
More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I've had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider - who they liked - abruptly stopped taking Medicare. One of the top mammographers in New York City works in my office building, but she no longer accepts Medicare and charges patients more than $300 cash for each procedure. I continue to send my elderly women patients downstairs for the test because she is so good, but no one is happy about paying.
Would it be so bad if more and more physicians decided to stop accepting Medicare? Physician/blogger Val Jones speculates it wouldn't be the worst thing in the world - and that it perhaps might even save money. She writes that her own physician runs a cash-only practice and that most of his patients spend around $300 a year on their care - less than a low-deductible health plan.
I think that people need to begin to accept that health care costs money. Primary care should be budgeted for (the way we budget for our utilities) and that "health insurance" should be "sickness insurance" with a high deductible for emergency coverage. The majority of Americans can afford $300/year in primary care fees, and the service they'll receive is far superior to what they have now. Government-run initiatives should focus on the very poor and inpatient services. Everyone else should enjoy the wonderful experience of having a personal physician available without long waiting lines or administrative and insurance hassles - all for the cost of less than we pay for TV.
Well, maybe. But even Dr. Jones notes this kind of arrangement seems to be best suited to people who are willing to pay cash for their care and who don't require hospitalization. I'm not sure how many Medicare-aged patients would fit this description.
Should Medicare patients just have to pay out of pocket to see a doctor who no longer accepts Medicare? Will these patients migrate to other doctors and possibly overburden the practices that still participate in Medicare? I'm not sure of the answers, and an overhaul of the Medicare program doesn't seem likely to happen any time soon. In the meantime, we can expect to hear about more seniors around the U.S. being left in the Medicare lurch.
Posted by: Anne Polta on February 01, 2010 at 10:07 AM | Comments (0) | Permalink
Tags: medicare
Polar madness
There's something about icy cold water that seems to bring out the come-on-I-dare-you factor among some people.
Local volunteers are taking a dip into the freezing waters of Green Lake at 2 p.m. Saturday to raise money for the Special Olympics of Minnesota. This is the sixth year the Kandiyohi County Sheriff's Office and Willmar Police Department have co-sponsored the Polar Bear Plunge as part of Spicer's annual WinterFest celebration.
Some co-workers here at the West Central Tribune participated in the Polar Bear Plunge a couple of years ago. According to them, jumping feet first into a lake in January isn't all that bad. "Exhilarating" is how a couple of them described it.
Uh huh. Whatever you say.
The human body is reasonably well equipped to survive a dunking in chilly water - but only up to a point. An article published awhile back by the Wilderness Medicine Society outlines the physiological response to cold-water immersion:
We now appreciate that sudden immersion in cold water (less than 60 degrees) initiates a series of incapacitating reflexes that increase the risk of drowning. Indeed, the most common cause of death from accidental cold-water immersion is drowning, not hypothermia.
The initial response, which affects breathing, heart function, and muscle strength, is called the Cold-Shock Response. This is a series of reflexes that begin immediately upon sudden cooling of the skin following cold-water immersion. The initial phase of the cold-shock response peaks during the first 30 seconds, and lasts just 2 to 3 minutes. During this time, blood pressure, heart rate, and the workload of the heart all increase, making the heart more susceptible to life-threatening rhythms and heart attack. Simultaneously, gasping begins, followed by rapid and deep breathing. These reflexes can quickly lead to accidental inhalation of water and drowning. This rapid and seemingly uncontrollable over-breathing creates a sensation of suffocation and contributes to feelings of panic. It can also create dizziness, confusion, disorientation, and a decreased level of consciousness.
The author, Dr. Michael Jacobs, warns people to "be prepared for violent shivering and intense pain" if they fall into cold water. And once they manage to get out of the water, hypothermia can quickly set in.
Cold water robs the body of heat 32 times faster than cold air and can "quickly numb the extremities to the point of uselessness," points out the U.S. Search and Rescue Task Force, which has done more than its share of cold-water rescues. The task force's advice: "If you should fall into the water, all efforts should be given to getting out of the water by the fastest means possible."
With the Polar Bear Plunge, of course, we're not talking about accidental immersion. The participants tomorrow are doing this on purpose. The water isn't deep, and EMTs will be on hand in case anyone gets into trouble. I'm told there's also usually a hot tub available where the volunteers can warm up afterwards.
But they're still subjecting themselves to a fair amount of discomfort - and all for a good cause. In case you're wondering, the weather forecast for Saturday calls for a high of 13 degrees and a wind chill somewhere between 8 below and 2 above. The least the rest of us (who are either smarter or more chicken-hearted, depending on your point of view) can do is support them by donating to the Special Olympics on their behalf.
West Central Tribune file photo by Ron Adams
Posted by: Anne Polta on January 29, 2010 at 12:08 PM | Comments (0) | Permalink
Tags: hypothermia, polar bear plunge
Radiation treatment gone wrong
It's the kind of story that can't help but be compelling:
As Scott Jerome-Parks lay dying, he clung to this wish: that his fatal radiation overdose - which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe - be studied and talked about publicly so that others might not have to live his nightmare.
Sensing death was near, Mr. Jerome-Parks summoned his family for a final Christmas. His friends sent two buckets of sand from the beach where they had played as children, so he could touch it, feel it and remember better days.
Mr. Jerome-Parks died several weeks later in 2007. He was 43.
A New York City hospital treating him for tongue cancer had failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.
The story, titled "Radiation Offers New Cures, and New Ways to Harm," appeared Sunday in the New York Times and has generated some intense online discussion and blog commentary.
Therapeutic radiation is commonly used to treat cancer; more than half of all people diagnosed with cancer will at some point receive radiation therapy. The technology has come a long way over the past couple of decades. Treatment is typically more targeted than it used to be, so healthy cells can be spared the collateral damage of radiation exposure. Refinements such as intensity-modulated radiation therapy, or IMRT, also are increasingly being offered to patients.
But it carries its own set of risks - risks that patients are often uninformed of, and that may not be adequately addressed by the industry. Furthermore, the increasing use of complex equipment, software and treatment protocols is raising the danger that errors will occur and patients will be harmed, the New York Times explains:
"Linear accelerators and treatment planning are enormously more complex than 20 years ago," said Dr. Howard I. Amols, chief of clinical physics at Memorial Sloan-Kettering Cancer Center in New York. But hospitals, he said, are often too trusting of the new computer systems and software, relying on them as if they had been tested over time, when in fact they have not.
Regulators and researchers can only guess how often radiotherapy accidents occur. With no single agency overseeing medical radiation, there is no central clearinghouse of cases. Accidents are chronically underreported, records show, and some states do not require that they be reported at all.
Many readers who commented on the story were appalled. "I could not finish reading this piece. It was an eternity of agony, even to get halfway through the narrative," one person wrote. "Horrifying," wrote someone else.
I count at least five separate and significant issues explored in the article and in the accompanying pieces: 1) the inherent risks of medical radiation; 2) the potential for medical devices to fail, especially as they become increasingly complex; 3) staff competence; 4) appropriate safeguards, checks and balances to ensure patient safety; 5) public accountability by the health care industry to investigate and prevent errors such as the one that killed Scott Jerome-Parks.
Although there's been increasing focus on the risks associated with radiation exposure from routine CT scans and X-rays, I question whether it's a fair comparison to therapeutic radiation. Radiation therapy has a specific intent, to treat cancer, so a whole different set of issues comes into play when making decisions whether to subject a patient to therapeutic radiation. Obviously, the amount of radiation required to target a tumor is also far greater and exposes the patient to significantly more radiation than any CT scan, albeit for the purpose of treating a serious disease. It can be a difficult tradeoff for cancer patients, who must weigh the potential risks of radiation treatment against the likelihood of the benefit.
If I were a cancer patient, I'm not sure how I would react to the New York Times story. Indeed, a number of commenters accused the reporting team of sensationalizing the issues and possibly scaring patients into making wrong-headed decisions. One person wrote:
While it is important to appreciate errors in medicine and swiftly correct them, particularly in an age of increasingly complex and computerized equipment, this article does a very effective job at frightening readers, particularly those with a personal experience of cancer therapy. The impression the reader takes is that there is gross negligence running rampant throughout radiation oncology departments as a matter of course. The article fails to mention the quite rigid quality assurance regulations in place for hospitals and physicians at the state and federal levels. This is a highly regulated field - not one of no oversight.
The American Society for Radiation Oncology issued its own statement this week, asserting that radiation therapy is still safe and effective and that errors are rare. A science blogger and cancer researcher offers his own take, drawing parallels between radiation therapy safety and surgical safety:
Reducing medical errors that harm patients is about more than just physicians. It's about the whole system. In surgery we have been discovering this (and struggling with it) over the last decade or so. It's not enough to just target the physicians. In my specialty and in the operating room, it's necessary that everyone be involved, from the nurse who sees the patient when he comes in, the physicians who do the surgery, the scrub techs counting instruments, the scrub nurse verifying surgical site - in essence everyone involved with the care of the patient from the moment he shows up for surgery to the moment he either goes home or is admitted to the hospital. Radiation oncology has at least as many people involved in the care of the patient, if not more: nurses, radiation physicists, radiation oncologists, technicians operating the machinery. Moreover, because unlike surgery radiation is often given in small fractions over many visits, there are many more opportunities for error than in surgery.
Ultimately, I think the reporting by the New York Times has done a major favor on behalf of patient safety. At one time, chemotherapy errors were rarely publicized and efforts to make this form of cancer treatment safer were occurring mostly in piecemeal fashion. This all began changing in the mid-1990s, after the death of Boston Globe reporter Betsy Lehmann, who mistakenly received a lethal overdose of a chemotherapy drug. There's now much greater awareness within the oncology community about medication safety, and a growing body of literature on chemotherapy administration procedures that have been shown to be safe and effective.
I'm not sure if this has been happening in radiation oncology to the same extent. A good start would be to develop a set of quality criteria - and to share them with the public, so patients and families can be better informed and in a better position to ask questions and advocate for themselves if something doesn't seem right. It's also essential to report errors and close calls in order to analyze what happened and redesign processes or systems to make them safer. After all, if you aren't tracking mistakes, it's nearly impossible to gauge how often they occur and what the contributing factors might be. Finally, there appears to be a need for more oversight - not just of hospital programs but of how the equipment and software are designed and manufactured and how the people who operate it are trained.
Injuries and deaths related to radiation therapy might be rare, but this is small comfort to patients and families who've had it happen to them. Surely the industry owes it to these people to do its best to be safe and accountable.
Photo: linear accelerator, Wikimedia Commons
Posted by: Anne Polta on January 28, 2010 at 3:31 PM | Comments (0) | Permalink
Tags: cancer, patient safety, radiation
Towards better hospital care
Right on the heels of the Minnesota Department of Health's annual report earlier this month on adverse events, the Joint Commission released its own annual report on hospital quality and safety in 2009.
The report tracks improvement over seven years, 2002 through 2008, on 31 quality measures that reflect the current best evidence on effective care for pneumonia, heart attacks, strokes, surgery and other issues that are among the most common reasons for hospital admissions.
Among the findings: There was sustained improvement on 12 of the measures and more limited improvement on 13. In two areas, both in the treatment of pneumonia, hospital performance slipped between 2007 and 2008. Data were submitted by 3,000 hospitals accredited by the Joint Commission, the main accrediting body for hospitals in the United States.
It's interesting to follow the progress from one year to the next. For instance, on one of the measures for heart attack care back in 2002, these patients were advised 66.6 percent of the time to stop smoking. By 2008, this had risen to 98.9 percent.
These days there's a lot of data being generated on hospital performance. The Minnesota Department of Health report, for instance, tracks "never" events, which by definition are both rare and serious. The Joint Commission's quality measures, on the other hand, focus on common, manageable issues shown to help reduce the likelihood of complications that can lead to morbidity, longer hospital stays and higher costs. Routinely giving antibiotics before surgery, for instance, demonstrably cuts down on the risk that the patient will develop a surgery-related infection.
Want to find out how a specific hospital fared on the Joint Commission's most recent quality report? You can search the online database at Quality Check, a tool developed by the Joint Commission and see detailed results.
There has historically been considerable variation in how hospitals have performed on these measures. In some cases, there wasn't a pathway to help ensure that best practices were consistently reaching every patient. Sometimes the correct steps were taken but they weren't documented in the medical record. And sometimes there may have been valid clinical reasons why a particular best-practice measure wasn't followed for an individual patient - a drug allergy, for instance, or other condition or circumstance that may have made a different course of action the wiser choice.
Quality measures aren't the be-all and end-all of hospital care. Some things, frankly, are hard to measure objectively. Advising patients who've been hospitalized with a heart attack to quit smoking might earn the hospital a checkmark in the appropriate box but it doesn't necessarily mean the patient actually followed through. Some of the measures that track whether the appropriate drugs were prescribed - an ACE inhibitor and beta blocker for heart attack patients, for example - don't really address questions of dosage or proper follow-up for the patient, which can be equally important in avoiding complications and ensuring a good outcome. There also should be room for some clinical judgment. What's good for 95 percent of patients may not be best for the other 5 percent.
Overall, though, performance measurement can be an enormously helpful tool for hospitals to track how well they're doing and benchmarking themselves against other hospitals. After all, you don't truly know if you're good, bad or ugly unless you have actual numbers; otherwise you're just guessing. And you can't genuinely improve and sustain your forward momentum for the benefit of patients unless you have a reliable way of measuring your progress.
West Central Tribune file photo by Bill Zimmer
Posted by: Anne Polta on January 27, 2010 at 2:11 PM | Comments (0) | Permalink
Tags: hospitals, joint commission, quality care
The obituary for health care reform?
In just one year, what a difference. A year ago at this time, there was a sense of - well, maybe not exactly optimism, but a sense of hope that we might accomplish meaningful health care reform in the U.S.
Now the reform initiative is on life support, and it's not clear what Congress might be able to salvage.
How did it all go wrong? Various commentators have been examining that question this past week. One of the most insightful analyses comes from Kaiser Health News, which points to congressional deal-making, the cost and complexity of the health care bills, and a failure to connect with the American public as the key reasons why health care reform legislation has faltered:
"There's nothing in it the average person could understand about why your costs would be lower," says Robert Blendon, professor of health policy at Harvard's School of Public Health. "They don't even have good illustrations about how it would be cheaper. They did not find a way to save money for people with job-based insurance."
... Certainly, relentless attacks by the Republicans - as well as the Democrats' own inability to clearly articulate the benefits of the legislation - are partly responsible for the legislation's lack of popularity. So are crucial policy decisions made by Democratic leaders as they struggled to push the legislation through Congress, according to experts of different ideological persuasions.
Does this mean the public no longer supports health care reform? Not so fast, cautions Bob Doherty, who blogs about health care policy for the American College of Physicians. Recent opinion polls suggest the real issue is that people are becoming doubtful and skeptical, Doherty blogged last week:
In my mind, the polls show that opponents have been most effective in raising doubts among Americans on two of the core claims for health care reform: that the bills will lower their costs while improving (or at least not hurting) the quality of care they receive. But I don't think that the polls show that there has been a wholesale rejection of the need for health care reform, or that most Americans buy into the view that it is too liberal and will lead to government-run health care. Instead, they don't trust that the bills being debated will deliver on the promises of better care at lower cost, and that is why a majority now oppose them. The proponents of health reform have not yet figured out how to make them feel otherwise.
It's worth noting that the MoveOn political action committee is holding an emergency rally at Rep. Collin Peterson's office in Willmar tomorrow to continue pushing for a meaningful health care bill, along with measures to support economic recovery. Clearly at least some among the public haven't given up yet, and don't want to see Congress scale back or abandon its efforts at health care reform. But is it going to be too late?
What I've seen (and heard) is that many people still care deeply about this issue and want to see genuine change. Many of them, however, have a hard time whole-heartedly supporting the bills on the table. Some of the disagreement seems to be ideological, but I also hear thoughtful people who are questioning whether the current version of reform will come at too high a price and create unintended - and damaging - consequences. Mostly, they're not sure how it'll affect them personally, and this uncertainty leaves them worried.
I blogged about this back in July but I'll say it again: Much of the process seems to have been dominated first by policy wonks and then by politicians. I'm not sure whether consumers or clinicians have truly had much say or whether they're actually being heard - a fact that was communicated loud and clear during the contentious town hall meetings last August. People are feeling disenchanted, and when they get disenchanted, they start to disengage.
Some of the controversy, I think, was to be expected. There's really no way to accomplish meaningful health care reform without goring a few oxen along the way. The question is whether we're losing the collective momentum we possessed one year ago. The clock is ticking. If the current reform effort fails, it'll likely be years before we regain the political will to give health care reform another chance.
Update, Jan. 29: For a collection of commentaries on the future of health care reform, check out Room for Debate at the New York Times.
Posted by: Anne Polta on January 25, 2010 at 11:29 AM | Comments (3) | Permalink
Tags: health care reform
The new look of local cancer care
One of the rewarding things about being a reporter is the opportunity to follow a long-term story as it unfolds. This has been the case with the Willmar Regional Cancer Center, starting a few years ago when Rice Memorial Hospital and Affiliated Community Medical Centers began seriously talking about combining their cancer services under one roof.
I've heard hospital and clinic officials, physicians and staff explain why they think this is a good move. I've seen the design phase of the $2 million project and toured the space several times while construction was under way. And having seen the finished product last week, it's not hard to understand why the folks involved in this project would be so excited about showing it off to the community this weekend. The open house/grand opening for the public is 1 to 3 p.m. Saturday.
Bricks and mortar aren't the only thing that's important, of course. It's the people who make the cancer center what it is. But you can do a whole lot more for patients when you have a physical environment that supports and enhances the services you provide.
The previous arrangement - having the radiation therapy program at Rice and medical/chemotherapy services at ACMC - has always been somewhat fragmented in terms of the patient experience. It also has hindered the establishment of a strong, unified identity for local cancer services, one that says "we're here and we can treat you if you're ever diagnosed with cancer."
Now there's one place patients can go for everything. They no longer have to figure out how to navigate two different buildings and two different parking lots. They can deal with the same staff each time. It gives them some element of familiarity and predictability at a time in their lives when the rug has been pulled out from under their feet.
The picture above shows the new entrance. It's much more visible than it used to be, and it's large enough to accommodate wheelchairs, plus family members, caregivers or whoever else might be accompanying the patient.
Here's the new waiting area:
And another view of the waiting area:
Even though patients and families are not here for a happy reason, the team that planned the design has done their best to reduce the intimidation factor and make it welcoming:
I have to say I'm impressed with the amount of thought that has gone into the details. For instance, there's now an on-site lab that makes it more convenient to do blood draws and other lab tests. This might not seem like a big deal, but keep in mind that cancer treatment can take a real toll on the patient's blood counts, especially infection-fighting white cells, hence people undergoing treatment need to visit the lab often to have their counts monitored. In the past, this has meant trekking down to the laboratory department at ACMC or at Rice. It was an extra thing for patients to deal with at a time when they were often struggling with fatigue, plus it risked exposing them to a whole range of other patients while they were immune-compromised. Now they can have their blood drawn right there in the cancer center - a small thing, perhaps, but one that helps make the treatment experience a little easier.
Ditto with the on-site pharmacy. In the past, all the drug solutions were mixed and prepared by chemotherapy nurses. Given that many patients on chemotherapy are each receiving an average of two to three intravenous drugs, plus pre-treatment IV steroids and anti-nausea medication, this can be very time-consuming. The on-site pharmacy is now staffed by Rice Hospital pharmacists, which has freed nurses to spend more time with patients.
One of the biggest physical improvements, in fact, is the chemotherapy environment. With chemotherapy sessions that can take two - and sometimes as many as six - hours, comfort matters. Patients now have their pick of an open treatment bay or a semi-private room. The treatment bay is large enough to accommodate up to six patients and is equipped with a big-screen TV and snack bar. There are eight semi-private rooms, each with TV, and roomy enough to include family members.
Nice chairs, pleasant lighting and art on the walls might not make much difference in a successful outcome, but if you talk to patients most of them will say they appreciate an environment that helps them feel physically and emotionally more comfortable. After all, they spend a lot of time here under stressful, demanding circumstances. If they're receiving chemotherapy, they more than likely will undergo multiple sessions of treatment. Radiation therapy generally requires coming in five days a week, often for anywhere from four to six weeks. Many patients have both chemotherapy and radiation, necessitating many, many visits over the course of months. On some level, the physical surroundings do matter.
And let's not forget the support services. By uniting under one roof, the Willmar Regional Cancer Center is now able to increase these. The staff is especially excited about a new nurse navigator program, which makes a full-time nurse available to help connect patients and families with extra resources, whether it's financial assistance they need or help with home care or nutrition. It's a service that, frankly, has been lacking in the past - and one that many patients and families sorely need.
One of the goals of the cancer center is to eventually start a survivorship program as well. It's increasingly being recognized that the transition out of active cancer treatment is, in its own way, as stressful and uncertain as the beginning of treatment. There has long been an unmet need for helping these patients make the transition. There's also a growing number of people who survive cancer, as well as people living long term with chronic cancer, who would benefit from support services aimed at helping them live as well as possible.
It's hard to put a dollar value on services such as a nurse navigator or a survivorship program. But just like the physical environment, these intangible things - the attentiveness, the personal approach - often do matter greatly to patients and families.
There's a tendency for people to shun their own back yard in the belief they'll get a better product or service by going out of town. And to be sure, there are times when cancer patients are best served by going to Rochester or the Twin Cities or elsewhere for the specialized care they need. But bigger does not necessarily mean better. There's a lot to be said for having this level of cancer care available close to home and knowing the quality measures and the outcomes stack up every bit as well as those at larger facilities.
West Central Tribune photos by Ron Adams and Anne Polta
Posted by: Anne Polta on January 22, 2010 at 3:17 PM | Comments (0) | Permalink
Tags: cancer, oncology, willmar regional cancer center
No respect for the thyroid
Pssst. Hey, you. Yes, I'm talkin' to you.
No, dummy, not your vocal cords. I'm your thyroid. I'm that important gland in your neck that produces hormones you need to help regulate your metabolism. More than that, I'm essential to many major functions such as your heart rate, your blood pressure, your body temperature and the basic activity of all the cells in your body.
Most of the time I just hang out quietly, doing my thing. I don't expect your gratitude - hey, functioning normally is just what I do. But right now I'm sorta having a pity party for myself. I mean, here it's January, national Thyroid Awareness Month, and I'm not sure anyone has taken the slightest notice. Come on, ask yourself: When's the last time you thought about your thyroid? You take me for granted, that's what, and I'm tired of getting no respect.
You'd think different if I went all haywire on you. Then you'd need me. Then you'd start paying attention. So consider this your wake-up call, your Thyroid 101, before it's too late.
First things first. I'm located in the front of your neck, nestled against your trachea (or "windpipe," if you prefer) and just under your larynx. I have a rather pleasing symmetrical butterfly/bowtie-like appearance. As organs go, I'm not all that big - maybe around 2 inches high and weighing anywhere from 18 to 60 grams in an adult - but I'm definitely one of the largest endocrine glands in your body. I'm covered with a nice fibrous sheath - an overcoat, if you will. If you cut me open and look inside, you'll see that I'm made up mostly of round follicles encased in thyroid epithelial cells, with a bunch of parafollicular cells scattered around for good measure.
I operate on a delicate and complex feedback loop involving me, the pituitary gland at the base of your brain and the hypothalamus within your brain. When everything is working the way it should, all the important thyroid hormones are manufactured and released at the proper levels and you feel hunkydory.
But I can be finicky and sometimes stuff just goes wrong. I might start producing too little thyroid hormone, which can cause you to become hypothyroid - or the opposite, too much hormone, which results in hyperthyroidism. Sometimes I get hit with an autoimmune disease such as Hashimoto's or Graves' disease and I stop working normally. It's the same deal with radiation exposure; I'm susceptible that way. I can develop nodules, most of which are benign but can occasionally cause problems. Sometimes I become enlarged (maybe you've heard of goiter). Sad to say, I get cancer too, usually curable but sometimes not.
Here's the thing that upsets me. Despite all the ways I can wind up in trouble, I'm often the last culprit anyone thinks of. Don't get me wrong; it's a relief to not always be the scapegoat for people's health problems. But you'd think I was invisible or something, or that what I do doesn't matter. Where's the respect in that?
According to the people at the Thyroid Awareness Month campaign (and you should listen to them because they're my BFFs), at least 30 million Americans have some form of thyroid disease. Many people with thyroid dysfunction aren't even diagnosed, however, so the real number might be closer to 59 million.
You know what really annoys me? When I develop some kind of problem, my symptoms can be so, well, non-specific. If I go hyper on you, you might feel anxious or jittery or overheated but it can easily be written off as nervousness. My hypothyroid symptoms - weight gain, sluggishness, depression, mental fog, feeling cold all the time - are constantly mistaken for other things. Like I said earlier, I don't always want to get all the blame if you're not feeling well. But I don't appreciate being ignored either.
And make no mistake, when I'm not functioning well I can make your life miserable. If you don't believe me, check out all the love letters written to me at Dear Thyroid. (Some of these people are really angry and they use a lot of four-letter words, so don't say I didn't warn you.) I'm not sure I deserve to be the target of their anger; after all, I can't help it when I screw up their lives. I'm just saying: You're a babe in the woods if you think thyroid dysfunction is no big deal, easy to treat, just take a pill every day and you'll be fine. For a lot of people it doesn't work this way at all. Not that I want to rain on everyone's parade here; for plenty of people, fixing what ails me is a relatively simple and straightforward thing to accomplish, and happy endings always make me happy. I'm just saying: I can be rather complicated sometimes.
So there's your introduction. Take some time to read all those links I posted. Get to know me a little better. We're in this together, after all; we need each other. And while you're at it, how about taking me a little more seriously from now on? I just want some respect. Is that too much to ask?
Posted by: Anne Polta on January 21, 2010 at 10:02 AM | Comments (0) | Permalink
Tags: thyroid
Mountains beyond mountains
True stories can be far more compelling than any fiction, which explains why I quickly became engrossed a few years ago in reading "Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World."
It's the story of a public health doctor and infectious disease specialist who has devoted himself to one of the most poverty-stricken corners of the globe - rural Haiti. Here, in the central highlands, Dr. Farmer helped establish a hospital and health center that became the cornerstone of Partners in Health, the nonprofit organization he co-founded to bring needed health care to the poorest of the poor.
Pulitzer Prize-winning author Tracy Kidder was in Haiti in 1994, reporting on American soldiers who were in the country on a peacekeeping mission, when he met Dr. Farmer. Eventually he decided to write a book about this extraordinary doctor, his work in Haiti and the daunting issue of global health, especially among the poor. "Mountains Beyond Mountains" is the result. (The book's title refers to a Haitian proverb that describes the never-ending hardships and challenges of life: "Beyond mountains there are mountains.")
It's an illuminating book, not only for the light it sheds on Haiti and its history and culture but also for its examination of global poverty and the impact of poverty on health.
Here's how Haiti fares in some of the most recent statistics collected by the World Health Organization: three physicians for every 1,000 people; one nurse or midwife per 1,000 people; less than one dentist per 1,000 people; 13 hospital beds for every 10,000 people. (Figures are for 2007, the most recent year for which complete numbers were available.) Given such a fragile health care infrastructure, it's not hard to see why last week's earthquake has had such a profound and devastating effect on the Haitian people.
Dr. Farmer's organization, Partners in Health, is working to raise funds and coordinate donations and volunteers for earthquake relief. Follow the link to read more about the "Stand With Haiti" campaign, including reflections by Dr. Farmer, the personal account of a physician's first 12 hours on the scene in Port au Prince, and a blog post by author Tracy Kidder. And I'd highly recommend reading "Mountains Beyond Mountains." A copy of the book is available at the Willmar Public Library.
Update: As the focus shifts from trying to rescue people to caring for the survivors, the health crisis in Haiti is deepening. This story, which appears today in USA Today, explains the challenges ahead. Doctors Without Borders also has posted a firsthand account and slideshow on its Web site.
Photo: Daniel Morel, Wozo Productions
Posted by: Anne Polta on January 19, 2010 at 10:01 AM | Comments (0) | Permalink
Tags: earthquake, global health, haiti, poverty, public health
