Now Viewing: Health Care Quality

How Not to Flip Out: Flip the Clinic

Jan 27, 2015, 4:38 PM, Posted by Beth Toner

Flip the Clinic San Francisco January 2015 Hard at work at the first regional Flip the Clinic meeting in San Francisco

“If you’ve been waiting more than 15 minutes, please see the receptionist.”

That’s the sign that was posted on a bulletin board in the radiology clinic where I was waiting for an MRI earlier this month. The funny thing? It was so lost amid the other postings around it screaming for attention that I only saw it on my way out, as I waited for a copy of the disk with my MRI on it. It struck me as odd, and a little concerning; did that mean I should be worried the clinic staff might have forgotten about me if I’d been waiting more than 15 minutes?

Don’t get me wrong: I understand that unpreventable delays happen. For me, the most frustrating aspect of signs like this is that they take the power away from the patient. 

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How Cataract Surgery Helped Me See the Future of Health Transparency

Dec 12, 2014, 1:34 PM, Posted by Risa Lavizzo-Mourey

Robotic Surgery

More and more health care costs are shifted to consumers. So why, asks RWJF President and CEO Risa Lavizzo-Mourey, can’t we easily discover and compare health care costs and quality?

Here’s how the subject came up. Recently, Lavizzo-Mourey underwent cataract surgery at an outpatient center in Philadelphia. No matter whom she talked to—and she was shunted from one person to the next—she could not learn the all-in cost of the procedure.

Lavizzo-Mourey finally did manage to find out the cost of her surgery: $2,000, including co-pays and deductible. But the whole episode, she says, is illustrative of a larger problem.

Writing in a recent blog post on the professional social networking site LinkedIn, Lavizzo-Mourey asks: “Could there be a clearer example of the lack of transparency in the U.S. health care system?”

To get the information we need, the Robert Wood Johnson Foundation is funding a set of studies to help us better understand how greater price transparency influences consumer and provider decisions. “And in March,” Lavizzo-Mourey adds, “we will host a summit on transparency that will attempt to come up with more answers."

Along those lines, RWJF last year issued a challenge to developers to devise consumer-friendly tools to parse the abundant hospital price data released by Medicare. The winner? Consumer Reports, for the Consumer Reports Hospital Adviser: Hip & Knee, a personalized app for health care consumers seeking the best hospital for hip or knee replacement surgery.

You can help us move the cost and quality needle forward. Do you know of any other price/quality apps or tools? Let us know.

Transparency in Health Care? Sadly, That's Not How We Roll.

Nov 7, 2014, 3:13 PM, Posted by Andrea Ducas

Patrick Toussaint Andrea’s husband, Patrick Toussaint, using his super strength to tighten a lug nut.

What do changing a flat tire and scheduling a surgical procedure have in common? Nothing. And that’s the problem.

Last month, on our way home to New Jersey from Boston, my husband and I got a flat tire. And while this is a dreaded possibility on any road trip, it happened to us at 9 p.m. on a Sunday. No shops were open, and with an early morning flight just a few hours away we didn’t have time to wait for AAA.

At this point it’s important to emphasize that neither my husband nor I know a thing about cars. We didn’t even know we had a jack or spare in the trunk until we called my uncle, who teased us (“You have a new car! Everything you need is in the back!”) and gave us the pep talk we needed. So we pulled out our owner’s manual.

I’m not sure who that manual is written for, but it clearly isn’t for us. After five minutes of thinking I’d need to call the airline and book a later flight, I realized: There is a better way. I pulled out my iPhone, Googled “how to change a flat tire,” and called up a YouTube video and a step-by-step, picture-guided Wikihow article. Within 20 minutes, the tire was changed, our spare was filled with air to 60 psi, and we were on our way.

So what does any of this have to do with health care? Unfortunately, not very much.

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Big (Box) Medicine?

Nov 6, 2014, 4:55 PM, Posted by Michael Painter

Lucy in the chocolate factory

Let’s see a show of hands. Who among us, doctor, nurse, patient, family member, wants to give or get health care inspired by a factory—Cheesecake or any other?

Anyone?

I didn’t think so.

True confession: I have never actually eaten at a Cheesecake Factory (hereinafter referred to as the Factory). My wife, Mary, and I did enter one once. We were returning from a summer driving vacation. Dinnertime arrived, and we found ourselves at a mall walking into a busy Factory.

It seemed popular. The wait was long—really long. We got our light-up-wait-for-your-table device. We perused the menu. There was a lot there. Portions seemed gigantic. We looked at each other and, almost without speaking, walked back to the hostess, returned our waiting device and left.

You got me—I cannot say 100 percent that I wouldn’t love Factory food. We were so close that one time!

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Helping Physicians Do What They Got Into Medicine to Do

Sep 25, 2014, 10:02 AM, Posted by Anne Weiss

Two women are at a desk, one is counting money

“Health care was never intended to be the behemoth it's become. It was intended to be the place where people could get help for medical problems so they can return to living a healthy life.”

For me, this statement—from an internist I met last month—is a refreshing take on the value of the health care system in a Culture of Health. It’s an inspiring vision for those of us focused on the usual litany of problems: Our health care system costs too much, and delivers outcomes that lag behind other countries to such a degree that it threatens our economic health and social fabric.

Last year, the Robert Wood Johnson Foundation (RWJF) invested in five markets—Maine, Minnesota, Oregon, Colorado, and the St. Louis region—where there is the will and ability to measure health care costs and quality, and use that information to drive change. In each of these markets, we’re working with multi-stakeholder organizations who are members of the Network for Regional Health Improvement (NHRI). Each organization will produce reports that compare the cost of treating patients in each primary care practice in their market. (You can learn more about this project here.)

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Patient Privacy: The Elephant in the Room

Aug 25, 2014, 12:30 PM, Posted by Al Shar

Albert Shar / RWJF

Albert Shar, managing principle at QERT and former Robert Wood Johnson Foundation vice president and senior program officer reflects on lessons learned from the RWJF-funded project, “Testing a system of establishing voluntary patient identification across multiple health care records to improve outcomes and reduce costs” (Shar is a guest blogger. His opinions are not necessarily those of the Robert Wood Johnson Foundation).

When it comes to improving patient safety, patient privacy is the elephant in the room.

Virtually every developed country except the United States has a method for identifying patients.  Misidentification of patients is not only costly and inefficient—it’s also dangerous.  According to data from the Institute of Medicine and the Joint Commission, in the U.S., nearly 60 percent of the 200,000 deaths per year caused by medical errors are cases of mistaken identity.

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Help or Hype: The True Costs of Robotic Surgery

Jul 14, 2014, 10:29 AM, Posted by Sheree Crute

Robotic Surgery

Joe Meyer is the model of a well-educated, engaged patient. A self-described “typical Midwestern guy” who settled in Chapel Hill, N.C., to raise a family and build a career, Meyer did everything in his power to make the best decisions when his 2013 physical produced unexpected and frightening results.

“I live a pretty healthy lifestyle. I exercise. I eat well,” says the 62-year-old chief operating officer of a large manufacturing company. “I was very surprised when my PSA test came back at 5.1 [3 to 4 is normal]. Further testing showed that I had prostate cancer.”

One of more than 200,000 men who are diagnosed each year, Meyer put his faith in his physician and the health care system when gathering information about treatment.

“After the biopsy, they told me my Gleason score was 7. [The higher the score on a scale of 1 to 10, the more likely a cancer will spread.] I realized I was high risk, so I started reading as much as I could about the choices I was offered—hormone therapy, radiation, or prostate removal.” He chose robotic prostatectomy over open or laparoscopic prostatectomy. Surgery, as opposed to hormone therapy or radiation, was widely considered a good decision for someone with Meyer’s prognosis.

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Choosing Wisely: Intensifying the Spotlight On Health Care of Dubious Value

Apr 30, 2014, 8:52 AM, Posted by Susan Dentzer

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“If you study the kinds of decisions that people make, and the outcomes of those decisions, you’ll find that humanity doesn’t have a particularly impressive track record,” write the brothers Chip and Dan Heath in their masterful book Decisive. Invoking research from psychology and behavioral economics, the Heath brothers demonstrate how people often make decisions by looking at what’s in the “spotlight”—the information immediately before them, sparse as it may be.

But what’s in that spotlight “will rarely be everything we need to make a good decision,” the Heaths counsel. To choose wisely, we need to broaden our focus, or “shift the light.”

That’s especially true in health care, where the consequences of any decision, poorly made or not, may be life or death.

Enter Choosing Wisely, a program that shifts the spotlight onto many of the tests and treatments that both providers and patients should question, if not abandon completely.

(Editor's note: On May 2, 2014, RWJF held a First Friday GoogleHangout to explore how Choosing Wiselysprang from critical examination of the overuse of medical care in the United States—and how it’s changing how care is delivered in communities. Watch an archived version of the Hangout, above.)

This two-year old campaign, launched in 2012 by the American Board of Internal Medicine Foundation, has identified more than 250 tests and procedures that warrant scrutiny because they are ineffective, unnecessary, unsupported by evidence, or possibly harmful. Even so, physicians and other clinicians perform them regularly, and patients sometimes request them.

Fifty-four of the nation’s premier medical specialty societies have joined the Choosing Wisely effort, and most of these have contributed to their own lists of questionable care. This week, three non-physician groups will also sign on to the campaign. Among the categories of dubious care identified on various societies’ “top five” lists are these:

  • Excessive imaging: CT or MRI scans for low back pain shouldn’t be ordered within the first six weeks of treating a patient, unless there are severe neurological symptoms, while patients with minor head injuries shouldn’t routinely get a head CT unless they have a skull fracture or are bleeding. Excessive scans expose patients to radiation that increases their lifetime risk of cancer.
  • Unnecessary medications: Antibiotics are not effective against viruses and should not be prescribed for viral illnesses such as sinus infections or bronchitis, particularly in children. But doctors say they frequently feel pressured to write these prescriptions by anxious parents.
  • Superfluous screening or diagnostic tests: Patients with no symptoms of heart disease and are at low risk of developing it are still frequently subjected to electrocardiograms when they get routine physical exams, despite evidence that this routine screening doesn’t improve patient outcomes. By the same token, hospitalized patients may have their blood drawn countless times for costly diagnostic testing that often yield little useful information, and can contribute to anemia.

The Robert Wood Johnson Foundation is supporting Choosing Wisely with a $2.5 million grant to extend the influence of these lists beyond medical specialty societies and into communities. State medical societies in Texas, Oregon, Minnesota, Tennessee, Washington, and Massachusetts have undertaken steps to promote the lists, including developing continuing medical education courses for doctors. So have ten regional health collaboratives, such as Maine Quality Counts and the Washington Health Alliance outside Seattle (both are among RWJF’s Aligning Forces For Quality communities as well).

Consumer Reports and AARP are among organizations that have taken the lead in publicizing the lists for consumers. All told, these efforts have reached an estimated 170,000 or more physicians and 16 million-plus consumers. There’s even a Wikipedia page for the campaign, with the lists of tests and procedures curated by a “Wikipedian” in residence.

Caveats: Although more than 200 articles have been written about aspects of the campaign in medical journals, there is as yet little hard evidence that is has reduced superfluous care. A recent perspective in the New England Journal of Medicine noted that the specialty societies’ lists “vary widely in terms of their potential impact on care and spending”—and suggests that some societies omitted lucrative elective procedures, such as knee replacement surgery, that also aren’t appropriate for many patients.

The bottom line: As a nation, we need to shine a spotlight on an even broader range of questionable health care in the future. But for now, the Choosing Wisely campaign is illuminating plenty of “care” that we can clearly pass up with impunity as we pursue our real objective:  better health.

 

ACOG Issues New Guidelines to Curb Overuse of C-Sections

Feb 27, 2014, 5:27 PM, Posted by Tara Oakman

Tara Oakman Tara Oakman

While I knew that having children would turn my world upside down, I assumed that this transition would be more metaphorical than literal. Ha! Moments before I was discharged from a Maryland hospital a few days after my twins were delivered by c-section, the ground shook violently. My husband had just left the hospital room to get the car, so I was alone with two newborns and a painful surgical wound. All I could think was ... “This is an earthquake! I have two babies. And I can’t move!

One of the scariest parts of the experience was that I couldn’t respond to my maternal instinct to quickly pick up and protect my babies because I had just had major abdominal surgery. Granted, managing in an earthquake is not a common part of recovery from a C-section, but there can be many other dangerous complications that occur more frequently, such as infection, emergency hysterectomy or heavy blood loss. It can also lead to greater difficulty with breastfeeding. C-sections are also very costly, even if there are no major complications. They are much more expensive than vaginal delivery.

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Aligning Measures to Improve Quality

Feb 11, 2014, 4:51 PM, Posted by Gerry Shea

Doctors go over a patient's charts in the emergency room.

The quest over the last decade and a half to define and quantify “quality” in health care in the United States has resulted in widespread use of quality measures. Unfortunately, the alignment of these measures among entities in both the private and public sectors has been secondary to the efforts to identify and use good measures. This failure has resulted in a tremendous lack of comparability between quality improvement efforts.

While not surprising, the near total lack of alignment has become a major obstacle in the effort to improve care for patients. It leads to significant burdens for those looking to improve, wastes valuable (and finite) resources and is a drag on overall quality improvement efforts. Additionally, it creates a considerable barrier to efforts encouraging value-based decision making by consumers and others.

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