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Yearly Archives: 2014
I was in Canada visiting my parents. I took a vacation from my job on the US East Coast. I often hear my US colleagues say how nice it would be to live in Canada, how the country cares for it’s people, provides lots of social services, just what a nice country should be. I grew up in Vancouver and after med school and working a while in Calgary, I moved to the US in 1992.
Here are some of my thoughts about the differences between the two countries. A lot of the hardship that seems more apparent in the US results from the fact it is a country of formidable size, so crime and poverty splash all over the news. Here’s some bad news: since I left Vancouver there seems to be as much crime as in the US – my mother lives in an upscale neighborhood and she has had several break-ins, as have all her friends. Despite the ‘free’ healthcare, downtown Vancouver is crowded with street folk who look as ill and unkempt as any you would find in Philadelphia or New York City.
As for the widely touted government funded social support in Canada, some say the social security there is more a trampoline than a safety net – rather than encouraging people back to work, many are content to collect unemployment benefits forever.
This government social network is tax funded which accounts for significantly higher costs of everything in Canada. I went to the grocer, Safeways, last night. A 3/4 pound bag of Starbucks which is $7-8 in the US costs $12 Canadian. A carton of Breyers ice cream is $4-5 in the US but sells for $11. The tax on beer is about 50% so a case of 24 varies from $26 to $38. Wine is very expensive. As for cigarettes, the price is enough to make one to quit for good. Gas is taxed to the lofty height of $6/gallon.
The only good news is that my family pays nothing for healthcare, not even a co-pay. Waiting is expected so when Mum had renal failure, she had to wait a few months to see the kidney specialist, but the consult and treatment was free, supported by the high taxes and high cost of everything.
In the Time Magazine March 10 2014 edition there is an article on how the Affordable Health Care Act’s Healthcare.gov site was fixed.
When the healthcare.gov site was launched in October 2013, a mere hundred or so users caused the site to crash.
Typical of government led initiatives, the different sections responsible did not work in unison and there was no clearly identifiable person in charge of the site. Different parts did not know what was going on, so each assumed all was well and progressing forward. The Centers for Medicare and Medicaid (CMS) spent over $300 million on building a website that did not work. Their tech people forgot simple things like creating a cache, where most frequently accessed information is stored in a layer above the database. In that way queries could proceed quickly and not tie up the entire site – this is done in commercial sites.
The White House was forced to hire properly skilled tech folks from companies like Google to revamp the health care website. The newly hired consultants found that the original government designed site “hadn’t been designed to work right…that any single thing that slowed down would slow everything down.” Many of these troubleshooters fixed the site at a fraction of their usual pay. The lesson is that rich government contracts are awarded to incompetent cronies or to the lowest bidder. Since this is not a meritocracy, it’s unlikely that contracts would go to the most qualified at the onset. The good news for the government is that others can be hired later to do repairs.
Since originally there was no leader of healthcare.gov, we will never find out who was responsible for this mess and why so much money was wasted in the first place.
My hospital asked me to lead a quality initiative for rectal cancer using the ProvenCare model. ProvenCare uses evidence-based best practices to reliably give the best care to every patient. The goal is to reduce unnecessary variation in care, ensure all patients receive essential components of care and optimize patient outcome.
In 2003 Elizabeth McGlynn of the RAND Corporation published a study in the New England Journal of Medicine on the quality of care delivered in the US. Despite readily accessible standards of care in the literature, 45% of patients do not receive recommended care. This deficit in care is a threat to the health of Americans. It also represents unwarranted variation and inconsistency in care delivery, increases costs and affects clinical outcomes. Wouldn’t it be better if every doctor gave every patient the proper care at the right time, all the time?
My hospital rose to the challenge. With the help of a its electronic health record, it re-engineered the complex processes of care, reduced unwarranted variation and reliably delivered evidence-based care for specific diseases.
The ProvenCare model was first developed for elective coronary artery bypass grafting and hit the airwaves with revelation of a sort of money back guarantee. It has been used for bariatric surgery, hip replacement, cataract surgery, coronary stenting, lung cancer, with many other projects underway. Notably the lung cancer model was adopted by the American College of Surgeons’ Commission on Cancer and is being studied in 12 centers. The model came up with 38 elements of care based on evidence-based guidelines. Initial results show the initial six participating hospitals followed 90% of the 38 elements of care.
While some argue, mere compliance with process measures does not translate into better outcome, for many of the above diseases, Provencare has resulted in:
- Increased adherence to evidence-based guidelines
- Improved clinical outcomes
- Increased patient engagement
Rectal cancer represents a unique challenge. About 40,000 new rectal cancers are diagnosed yearly in the US and half will die from this cancer. While some may think most of these patients are treated at major cancer centers by colorectal specialists, only a small percentage receive such care. Most rectal cancer patients are treated by non-specialists in low-volume hospitals. As a result, there is a great variation in how the care is delivered and a great variation in the outcome. The literature shows that local recurrence can be as low as 0% and as high as 37%. Surgical mortality varies between 1.4% to 7% at the high end. The colostomy rate also varies throughout the country. Rectal cancer surgery is difficult as the cancer can be low, confined by a narrow bony pelvis. This can result in incomplete removal leading to local recurrence and death or hinder making an anastomosis (putting the rectum back together).
In addition to the surgical problems, patients should have high quality imaging of the tumor with either endorectal ultrasound or pelvic MRI but many hospitals do not have these tools. Some patients may need radiation and chemotherapy before or after surgery and may never receive it. Some could benefit from a multidisciplinary approach where each patient’s case is reviewed by a team of surgeons, medical and radiation oncologists and other providers. If that patient’s hospital does not have such a team, that team approach is not offered. After surgery accurate assessment of the tumor stage and the margin (how deeply the cancer invades the rectum) affects prognosis and treatment planning. Ideally this is best done by specially trained pathologists which can ensure the quality of the surgery.
So with a team of ProvenCare specialists, the rectal cancer project is underway. This plan will take about 40-50 weeks, with a meeting every week. The project is in 7 stages and presently we are reviewing the literature to identify the ‘best practices’ of rectal cancer care.
As each stage unfolds, I will continue to write about the process.
Today I was notified by Medical Records at my hospital that one of my OR/surgery reports was incomplete. I had done hemorrhoid surgery on a patient 6 weeks ago. Someone in the medical records department flagged a deficiency in my OR note. I had left out the “drain” section – whether a drain was used or not. For my lay readers, you need to know that while drains can be used in abdominal surgery, I have never used one for hemorrhoid surgery in 27 years. In fact I can’t think of any colorectal surgeon ever using a drain for hemorrhoidectomy. In any case I was in violation as the hospital Medical Record Procedure Committee stated that Drain recording is a requirement and has to be addressed in the Operative report. I was directed to Rules and Regulations page 14. Was the documentation of drains a ‘requirement’ of the committee because of government regulatory agency rules or did the committee feel that drains should be used in hemorrhoidectomy? I doubt anyone sitting on this committee knows anything about anal surgery, so it’s likely a misinterpretation or misapplication of a badly written regulation. If this documentation of drains is required, then this should be mentioned in all surgery despite clinical relevance or common sense. Taking this to a ridiculous end in my hospital, drain use should be documented for anal fissure surgery, removal of rectal foreign body and colonoscopy performed in the OR in spite of logic that drains are never used in these procedures. It is thoughtless mindless enforcement of such ‘rules’ and regulations which lead to more and more doctors leaving medicine in frustration.
In a survey by the Agency for Healthcare Research and Quality’s (AHRQ) survey of hospital culture, some revelations came to light. It was disturbing that 26% of health care workers say whenever pressure builds up, managers want them to work faster, even if it means taking shortcuts. Fifty percent said they work in a “crisis mode”, trying to do too much too quickly and disturbingly, 36% report that safety is sacrificed to get more work done. Safety does not seem to be the priority when managers/administrators exhort workers to do more and overlook repetitive safety problems.
This is probably the tip of the iceberg. Each hospital is already under financial stress. They are placing higher unattainable financial targets in order to clear their overhead expense and try to break even what with the government cutbacks, increasing expense of business, etc.
It is hoped that with evolution in healthcare funding, there will be less emphasis on volume and more on good outcomes and results from the care delivered.
Complications can occur when a patient receives care. In fact, some patients develop a complication such as a wound infection after surgery. When that happens I don’t feel it is due to a mistake or error but many hospitals approach this in a punitive way. An email/letter is sent to the doctor but to get the point across it is also sent to the Department Head, Chairman of Surgery, and various administrators, so the complication is for all to view. All this does is make doctors reluctant to report errors.
Dr. Lucien Leape from Harvard in testimony to congress said, “the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
Only by developing a “Just Culture” and transparency like the airline industry where errors are reported without punishment will lead to improvement in healthcare safety. Continuing to push providers and punish the bad outcomes will leave healthcare mired in the last century.