The ultimate challenge in controlling healthcare costs: reducing needless care

October 8, 2014  |  General  |  No Comments

Efforts to reduce overuse of health care services run counter to the dominant financial incentives in our fee-for-service system, challenge the cultural assumption that more is better, and raise concerns about stinting on necessary care.

That quotation is from a recent editorial in the New England Journal of Medicine. It points out the often quoted estimate that 25-35% of all medical care either doesn’t do any good or is actually potentially harmful, what the editorialist calls low-value care. That is a huge problem, one that will prove very difficult to solve.

The fundamental issue as I see it is that, although founded on science, medicine is very imperfect as a science. It’s a mixture of science, near-science, intuition, guesswork, and blind luck. Depending upon the disease or condition, the more uncertain portions of medical practice figure much more prominently than the certain ones. Over the past several decades we have tried more and more to use evidence-based medicine, that is, doing only things and using only treatments that hard evidence has shown to be beneficial. Unfortunately, rigorous studies of what works and what doesn’t work are difficult and expensive to do. More than that, a great deal of what we do doesn’t even lend itself to that kind of research. We’re often stuck with what committees of experts recommend based upon weaker studies or just opinions.

The other huge problem is with how fee-for-service medical practice works: doctors are generally paid  much more for doing things than for not doing things. Low benefit or even useless treatments represent somebody’s revenue stream; limiting or even eliminating them takes money out of practitioners’ pockets, creating a strong impetus to keep going as we are. But the enormous cost may finally be convincing the public that something has to change:

Public acceptance of a role for policy in reducing the use of low-value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs.

I have no doubt that ultimately physicians will be told what they can and cannot do, most likely through the mechanism of what insurance payers will pay for. We’ve been seeing various forms of that kind of limitation for years and the process will accelerate. The mechanism of high co-pays was hoped to help by giving patients a financial incentive to avoid needless medical care. But there is a problem with that, too.

Demand-side interventions — targeting patients — principally include financial incentives and education. Increasing patient cost sharing is a blunt instrument: research shows that it can reduce use of both low- and high-value care, which suggests that patients do not have the information or skill required to differentiate between the two.

Many people outside the medical field think that applying simple market principles would help. If things cost so much, why not just increase the number of physicians and let them compete with each other on cost. Surely the result would be, as with other supply and demand commodities, that costs will come down. It doesn’t happen that way. In medical care, supply drives demand rather than the other way around. Adding more physicians who do things results in more things being done, something known for 50 years.

I don’t know what will happen with all this, but something will. But this will be the general direction:

To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value.

A smartphone app for jaundice, effects of digital media on children’s brains and more: Pediatric Newsletter #10

September 30, 2014  |  General  |  No Comments

Here is the latest of my more or less monthly newsletter on pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health that I think will interest parents. If you want to subscribe to it and get it in the form of an email each month there is a sign-up form at the very bottom of my home page.

Coming soon: A smartphone app to see if your baby is too jaundiced

This bit of news is pretty interesting, although the product is still in development. These days babies typically go home from the hospital when they’re a day old or even less.Newborn jaundice is very common, especially in breast-fed babies. Nearly all the time it means nothing and passes without treatment. Once in a while, though, the blood bilirubin, which causes the jaundice, gets dangerously high. We treat it with phototherapy. It takes a blood test to measure the blood level, although we’ve used devices for years in the hospital that estimate it from the skin color, identifying those babies that need the blood test. Now it looks as if there will be a way to screen your baby at home using your cell phone and then sending the results to you doctor. I think it’s a cool concept.

Let them sleep in more: American Academy of Pediatrics recommends delaying school start for adolescents

Every parent with a teenager knows they like to sleep more. To no one’s surprise, this is because they need more sleep to be healthy and sharp for school. Research has shown real benefits for mental and physical health. Starting school at 7:30 in the morning, or even earlier, is particularly hard for adolescents. Recognizing this, the AAP has come out with new recommendations for middle and high school start times, suggesting 8:30 am as more appropriate.

Who knows if this will go anywhere because the logistics of getting kids to school and parents to work on time can make it tough to change things. After school activities, such as sports, would also be affected if practice times are pushed back. But it seems pretty clear that a later start would be better for teenagers.

Children who use digital media a lot may be less able to read actual human emotions

This one is interesting. All of us, especially children, are spending a lot more time staring at digital screens — computers, smart phones, video games. A research report coming out next month suggests this may not be a good thing for emotional development. Children, who have not yet fully developed human interaction skills, may be less able to read emotions on actual human faces if they spend a large amount of time with screens.

The researchers found that children whose access to electronic devices was limited were better able to read other people’s emotions. The authors concluded: “Decreased sensitivity to emotional cues – losing the ability to understand the emotions of other people – is one of the costs. The displacement of in-person social interaction by screen interaction seems to be reducing social skills.

“I’m not surprised by this, really, and I find it concerning. It’s one of several reasons my wife and I monitor and limit our son’s computer and smart phone time.

High levels of physical activity linked to early academic achievement

Every parent knows that physical activity is good for children. Among other things, being active and not parking in front of the TV is linked to a lower level of obesity. A new study from Finland suggests that a higher than average level of physical activity is also linked to improved academic performance in elementary students, particularly among boys.

The authors observed 186 children during recess for the first 3 years of schooling and also collected other information on physical activity, such as riding a bike to school: “The improvements in academic attainment were most striking in male participants, especially with reading skills. Boys with higher levers of physical activity, and in particular walking or cycling to school, had better reading skills than the less active boys.

“I was interested to see this research but it seems to me to be confirming common sense. What it is really saying is that if you encourage children, especially boys, to run around a lot and work out their energy, they concentrate better in the classroom. It reminds us that old-fashioned recess is getting rarer and rarer. A half-hour of unstructured play time used to be common; it no longer is.

Finally, an effective treatment for respiratory syncytial virus (RSV)?

September 22, 2014  |  General  |  No Comments

Respiratory syncytial virus infection, aka RSV, is a common infection in children. A key aspect of RSV is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first few years of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics. Every year a new crop of susceptible infants enters the population.

The most common form of RSV infection is called bronchiolitis. In medical terminology, adding the ending “itis” to a word means that whatever comes before is inflamed. Thus tonsillitis is an inflammation of the tonsils and appendicitis means an inflamed appendix. So bronchiolitis is an inflammation of the bronchioles, the final part of the system of air-conducting tubes that connect the lungs with the outside world. Beyond the bronchioles are the aveoli, the grape-like clusters of air sacs where the business of the lungs — getting oxygen into our bodies and carbon dioxide out — takes place.

Bronchiolitis is a disorder of blocked small airways. This prevents air from getting in and out normally, primarily out. In bronchiolitis, the main problem is that the bronchiole tubes are blocked from swelling of the walls and from debris caused by the RSV infection — bits of broken airway cells and mucous plugs. It looks like this, with the arrows showing air movement.

Infants are the ones who have the most trouble breathing with bronchiolitis. There are several reasons for this, but a key one is the construction of an infant’s chest. When small airways get blocked, we use our chest muscles — tightening them — to force air in and out of our lungs. We are helped in doing this by the fact that our lungs are encased in a fairly rigid rib cage; when we use our muscles to squeeze or expand our chest the system works like a bellows. Infants can’t do this well because the ribs across the entire front half of their chest are not yet solid bone — they are still soft cartilage.  So when a small infant tries to suck air in against anything that is restricting airflow, like clogged bronchioles, his chest tends to sink inwards, causing what we call retractions. These are easiest to see just below the last ribs. They also have trouble forcing air out, so their chests become hyperexpanded with air, making it look as if their chests are puffed out a little. The other reason infants have so much trouble handling debris in their bronchioles is that these tubes are already much smaller to start with, so they get more easily clogged up than do the larger airways of older children.

We have never had any specific treatment that works for RSV bronchiolitis. All we can do is what we call supportive care — oxygen, some breathing treatments (which usually don’t help much), IV fluids if the child is too sick to eat, and a few things we can do to help with mucus clearance. But now that may be changing. A recent study looked at a new drug to kill the RSV virus directly, something we’ve never had before.

The drug, which can be given orally, was tested on adults, not children — yet. The results were very encouraging. One of the issues with other anti-viral drugs has been that they only work well if they are given very early in the course of the illness or even before symptoms start. This new anti-RSV drug works even after people are sick with the virus. It greatly reduced the amount of virus in respiratory mucus, where we usually find the virus. Perhaps more importantly for sick infants, it also caused rapid improvement in symptoms.

Dr. Peter Wright, an RSV expert, is excited about the possibilities of the drug. Dr. Wright has worked on RSV for many, many years — so many that he was one of my teachers at Vanderbilt Hospital way back in 1978. I can recall that he does not get excited easily. I’m excited, too, because severe RSV bronchiolitis is a real scourge we see frequently in the PICU. Some infants even die from it. I was also pleased to read that Dr. Wright is still on the RSV case after all these years.

Pediatric Newsletter #9

August 23, 2014  |  General  |  No Comments

Here is the latest of my more or less monthly newsletter on pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health that I think will interest parents. If you want to subscribe to it and get it in the form of an email each month there is a sign-up form at the very bottom of my home page.

At what age to overweight and obese children start getting that way?

Most parents are aware that the average weight of America’s children is going up — more and more kids are overweight or obese. Experts debate the reason for this but we know it is happening. We have piles of data documenting the percentage of children who weigh too much, but until now we haven’t known the answer to a key question: When did they start to become that way? This is a key question because it would tell us where to concentrate our intervention measures. Now we know.
To understand this better you need to understand the difference between two key terms – incidence and prevalence. Incidence is the number of new cases of something in a year; prevalence is the overall number of cases of something in the population at a given time. We have known a lot about the prevalence of childhood obesity but, until now, nothing about the incidence. That is, we didn’t know when the large number of obese children first got that way.

This research article, which got wide coverage in the medical press, contains the important information. It uses year by year weights of several thousand children to see at what age individual kids became overweight and obese.

The answer? KINDERGARDEN! That is, age five is when the largest number of children who were to become overweight and obese first started becoming that way. More than that, it may be even younger because the number of overweight and obese five-year-olds was already pretty high.

The article is in a medical journal but is worth a look if you are interested in the topic. You can see the summary without a subscription and it is quite clear.

If you want to know the scientific definitions of what the categories “overweight” and “obese” mean, and how to measure your own child, the Centers for Disease Control has a good source here.

Football concussions in high school players: how you tackle matters

If you have a son who plays football you probably have heard a lot about concussions, which we now know are much more common than we previously thought. We also now know that they can be much more serious than just “getting your bell rung.” Getting multiple concussions, or another one before the symptoms of the first one have gone away, is very bad for the brain.

Although any blow to the head can cause a concussion, we don’t know if the location of the blow matters much. A recent study in high school players looked at the question. It turns out that a blow to the top of the head, such as when a player rams another player head-on, is more likely to cause one. I’ve never played football, but the authors point out that correct tackling technique is with the head up. It appears that the correct way to tackle is also the safest.

Why are teenage boys so fearless?

Every parent of a teenage boy knows that their ability to  judge risks is often not good. Why is that? Why do they seem to think they are immortal, and that bad things won’t happen to them? Is there something special about the teenage male brain? The answer appears to be yes.

A recent, quite sophisticated, study used high-tech brain scanning techniques to examine teenagers’ brains when exposed to a variety of simulated situations. The authors concluded this: “Adolescent males are relatively insensitive to punishment or losses, but hypersensitive to large gains.” From this they also speculated why punishment or threat of punishment alone is often not the best way to discipline an adolescent male.

So science may be demonstrating what parents have known for generations. Still, an interesting read.

Don’t ever give your child codeine cough syrup. Ever.

We’ve known for some time that codeine, often in the form of prescription cough syrup, can be bad for children. The side effects can be severe, especially in children under the age of two, but it can do bad things in older children as well. The main problem is that the effect on a given child is quite unpredictable. What’s more, these syrups don’t even work at suppressing cough. A recent study reports the discouraging news that physicians haven’t gotten the message; the number of prescriptions written for codeine cough syrup for children has barely changed in the last several years; it is still a very large number. Parents can help. If a doctor wants to write such a prescription for your child, say you don’t want it. You might also remind the doctor that medical experts are unanimous in their condemnation of these products. Also, codeine as a pain killer doesn’t work well for children. So don’t use it for that, either.


Sleep apnea in children: what do we know?

August 17, 2014  |  General  |  No Comments

Earlier this year a child died following a surgical procedure in California for a condition called obstructive sleep apnea. The case generated a great deal of concern among parents about both this condition and the surgery often done to treat it. I wrote a post myself about it at the time. I still get questions about it because I care for quite a few children immediately after they have had surgery for it : What is it? How do we diagnose it? How do we treat it? Is surgery always necessary?

Technically the word apnea means cessation of breathing, but what we generally mean by it is a significant pause in breathing. Generally we define an apneic pause as lasting twenty seconds without taking a breath. Most of us can hold our breath that long without difficulty if we mean to, such as when we dive beneath the water. But that is when we are awake and in control of things. Things are different when we are asleep. A person with sleep apnea is unaware of their abnormal breathing pattern because they are asleep, although as you will read it’s often not very healthy sleep.

The condition is called obstructive sleep apnea because the problem is the result of obstruction of air flow. The obstruction happens at the level of what we call the upper airway — primarily the back of the throat. When we’re awake we keep good control of the tension in the muscles around our upper airway. But when we’re asleep the muscular tissues back there relax. They may sort of flop together and this can lead to obstruction. Think of the passageway as a pipe. If you look in the mirror and open your mouth wide you can see most of the key components. The tongue is at the bottom of the pipe and top is composed of the soft palette toward the front and the adenoids toward the back, although you can’t see the adenoids because they are tucked up behind the soft palette at the back of the nasal passages. The sides of the pipe at the narrowest point are the tonsils. Right at the back of the throat the pipe makes a right angle turn and dives downward, so the tissue sat the back of the throat are also important. Obstruction of air flow happens when any of those components bulge out into the pipe to make it significantly smaller.

There’s a principle of physics that comes into play here. It was originally described for fluid flow through a pipe, but it also applies to air flow. The principle is that, if other things are kept constant, flow is proportional to the fourth power of the radius of the pipe. That may sound esoteric, but it has real, practical implications for obstructive sleep apnea. It means that a relatively small reduction in the size of the opening has a huge impact on how much flows through it. So if you make the airway pipe half as wide you reduce flow by a factor of sixteen. People with obstructive sleep apnea have the size of their pipe sufficiently reduced when asleep to block air flow, and this leads to problems.

What are those problems? They stem from not getting enough oxygen into the lungs, not getting enough carbon dioxide out of the lungs, or a combination of both. This causes a reduction in oxygen and a build up of carbon dioxide in the blood, not a good thing. The brain recognizes things are not right and responds by not really going into a deep, normal sleep; the person frequently partially awakens so that more normal muscle tone returns, briefly enlarging the airway — at least until he falls back to sleep. The heart has to work harder than normal. The vessels of the lungs can be affected in a bad way.

What are the symptoms of sleep apnea? The most common is severe snoring, especially when the person is lying on his back. If you listen to someone with sleep apnea snoring you often hear a pattern of steadily worsening snoring, then a pause in breathing, then a sort of snort as they arouse, and then a repeat of the cycle. People with the condition are often drowsy during the day because they never really get a good night’s sleep. For children, poor school performance is common because of this. A headache in the morning is often common.

How common is obstructive sleep apnea in children? A reasonable estimate is that around 1% of children have symptoms of it at one time or another. It may be increasing because the problem is associated with being overweight and the prevalence of that among children is increasing.

How do we treat it? There are really two ways, both designed to keep the airway open when sleeping. A treatment often used in adults is  CPAP, which stands for continuous positive airway pressure. The idea is that if you place a tight-fitting mask over the mouth and/or the nose and blow air through it down into the lungs, the pressure will hold the airway open. It can be very effective. As you can imagine, however, many children will not tolerate wearing this apparatus because it can be uncomfortable and the CPAP machine is noisy. The second option is surgery to make the airway bigger. That usually means removing the tonsils and adenoids, although sometimes working on other parts of the airway, such as the soft palette, is part of the procedure.

If you are concerned that your child has sleep apnea — perhaps she snores loudly, you hear pauses in her breathing while asleep, and she is drowsy during the day — how can you be sure? After all, we don’t want to be doing surgery needlessly. It’s an important question and we have some good practice guidelines to go by. The American Academy of Pediatrics has published these. The most important principle is that we have specific tests we can do, tests incorporated into what we call a sleep study. This makes measurements of blood oxygen levels and measures airflow through the airway while the child sleeps. For many years the studies were difficult to do in children, but now many centers can do them. My own view is that, for most children, surgery should not be done without these studies to confirm the diagnosis. The exception would be if the diagnosis is clear (severe, obvious obstruction when asleep) or the child already has signs of stress on the heart and lungs.

How good is the surgery in children? Does it work? A recent research study helps to answer that question. For most children, surgery helped their sleep pattern significantly. The investigators didn’t demonstrate improvement in cognitive function during the day, such as school performance, but the time frame may have been too short to show that.

How dangerous is the surgery? The California case demonstrates that it, like any surgical procedure, is not without risk. There may be excessive bleeding afterwards, although we have ways to deal with that. Although this kind of surgery is often “same day,” meaning you can go home some hours afterwards, your child may need to stay in the hospital overnight. This is particularly likely if the sleep apnea was severe. The figures I’ve seen put the risk of death, the ultimate risk, at somewhere between 1 in 12,000 and 1 in 15,000. The death risk relates not only to the actual surgery but also to the anesthesia required to do it.


A new study on the safety of home births: are they as safe as hospital births?

July 12, 2014  |  General  |  No Comments

From time immemorial until about 75 years ago or so most babies were born at home. Now it’s around 1% in the USA, although it’s much higher than that in many Western European countries. The shift to hospital births paralleled the growth of hospitals, pediatrics, and obstetrics. With that shift there has been a perceived decrease in women’s autonomy over their healthcare decisions. There has also been an unsurprising jump in the proportion of Caesarian section deliveries, an operative procedure, and various other medical interventions in labor and delivery. So the debate over whether this is a good thing or a bad thing (or neither) is much more than a medical debate; it is also a social and political one. It is also to some extent an issue of medical power, a struggle between physician obstetricians who deliver babies in the hospital and nurse midwives who often deliver babies at home. I’m very interested in the social and political aspects, but as a pediatrician I’m particularly concerned with the safety question: Is it more dangerous for your baby to be born at home?

There have been many studies that attempt to answer that question. Many, even most, of them come from outside the USA. The results are mixed. Some say hospital birth is safest (this one, for example), others that there is no difference (this one, for example). One US study that found home delivery to be riskier has had its methodology heavily criticized. What we need are some well designed, large cohort studies from the USA, especially since healthcare systems differ substantially from country to country. I think this recent study from the American Journal of Obstetrics and Gynecology is very useful in that regard.

The main question the authors tried to answer was how the babies did. The measure they looked at was to analyze the frequency of two well-accepted markers of infant distress, things that correlate with trouble later in development. Bear in mind that there can be many reasons for these bad things to happen — some avoidable, some not. The notion is that if one can study a large enough group, then particular circumstances for individual births will wash out in the totals.

The potentially bad things that the authors chose were easy things to count and document. The first was a low Apgar score at 5 minutes after birth. The Apgar score, scaled 0 to 10 and recorded at 1 and 5 minutes after birth, has been a standard, well validated measure of infant distress for many decades. A value of less than 4 is potentially very bad for the baby. The other measure the authors chose was seizures, convulsions, immediately after birth. These can be caused by many things, but most of them are bad.

The study group consisted of over 2 million infants born in 2008. Of these only 12,000 were planned home births (0.6%). This shows how uniform hospital birth has become in the USA, but 12,000 is still a very large group of babies. They excluded babies born unexpectedly outside the hospital.

The results showed that babies born in the hospital, as you would expect, had a very much larger percentage of obstetrical interventions of various sorts associated with their birth. Regarding the distress measures, 0.24% of hospital-born babies had Apgars of less than 4 at 5 minutes; this compared with a rate of 0.37% for babies delivered at home — 1.5 fold higher. This difference was statistically significant. Also significantly different was the rate of seizures: for hospital-born babies it was 0.02% and for home-birth babies it was 0.06%, or 3-fold higher.

So what does this mean? First, the incidences of both of these bad things, although statistically higher in the home-birth group, were still very low. That is encouraging. But to understand things better you need to dig deeper into the data and see who attended at these deliveries. In the hospital it was presumably a physician, but what about at home? After all, “home delivery” can mean many things.

In this study, 26% of the home birth attendants were certified nurse-midwives, 51% were other midwives, and the remainder something else. A key finding to me is that the outcomes for babies delivered at home by certified nurse-midwives were no different than for those born in the hospital. So proper training matters — a lot. One key thing a trained midwife should offer is the knowledge of which pregnancies are higher risk and unsafe to deliver outside a hospital.

Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have issued policy statements about planned home births. The bottom line to me is that, while neither society is thrilled with the practice, both say properly selected (and they give lists of what that means, which is itself a bit controversial, such as if previous Caesarian section should be a disqualifier), low risk pregnancies can be safely delivered at home. As a pediatrician, I should point out that if you chose that there are some routine things that need to be done for your baby in the first days of life, such as a hearing screen. So you should bring your infant to the doctor promptly for a newborn evaluation.

Procedure checklists: they can only work if you use them

June 11, 2014  |  General  |  No Comments

Complicated medical procedures can be dangerous, even when done by highly skilled and experienced people. Why? Because, irrespective of the procedural risk itself, all of us are human and we can overlook or forget things, no matter how many times we have done the procedure. This was recognized many years ago in the airline industry. Flying an airplane is a complicated and potentially dangerous activity and their are many steps to go through and check before takeoff. This is why, as you board an commercial airplane, you see the pilot and copilot going through a standardized list of things even though the pilot may have thirty years experience. Missing something can be fatal.

This process of formal checklists entered medical practice some years ago, first in the specialty of anesthesiology. It is one of the main reasons, along with new monitoring devices, that anesthesia is much, much safer than it was several decades ago. This approach then spread to other areas of medicine, in large part because of the work of patient safety guru Peter Pronovost. The idea is simple: for every procedure, rather than just tick things off in our mind like I was trained to do, we should go through a formal checklist process to make sure everything is correct and in place. Many of these are pretty simple things. Do we have the right patient? Are we doing the correct procedure on the correct body part? Do we have all the stuff we need ready to go for the procedure? This may sound sort of obvious, even silly, but there are many sad examples of physicians doing the wrong operation on the wrong patient.

The checklist concept really took off with Atul Gawande’s widely read book (it was a New York Times bestseller) The Checklist Manifesto: How To Get Things Right. The groundswell to establish checklists before and during procedures has now reached most hospitals. I know in my practice things have changed. In the past when I needed to do a procedure on a patient I just gathered up the personnel and equipment I needed and got started. Now we go through a checklist. An important part of the process is that any member of the team who has questions or issues is encouraged — mandated, really — to raise them. Now that I’m used to it, I like the new way better than the old one.

But the big question, of course, is if this increased role of formal checklists before procedures has done anything. Are rates of, say, wrong patient, wrong site, or other bad things improved? There are data showing that complications from at least one procedure, placement of central venous catheters, are reduced by checklists. But what else do we know? A recent article and accompanying editorial in the New England Journal of Medicine examined this question. The upshot is that things are murky.

The research study is from Canada. It looked at 3,733 consecutive patients at 8 hospitals that had implemented checklists for operative procedures. The bottom line was that there was no improvement in measurable outcomes. But hold on, observed the author of the editorial. As he saw it, the problem was that the checklists were foisted upon the operating room personnel without any preparation. There was apparently some resistance at the novelty of them, accompanied by gaming of the system — “dry-labbing the experiment,” as we used to say in the laboratory. The author’s point is that we really don’t know if the demonstrable success of checklists in some aspects of patient care can be generalized to other things. We hope so, but we don’t know for sure. The editorial author’s explanation for the findings of the research study is simple:

The likely reason for the failure of the surgical checklist in Ontario is that it was not actually used.

The perils of patient satisfaction scores

June 4, 2014  |  General  |  1 Comment

Nearly all physicians are now subject to patient satisfaction ratings. In my case, and many thousands of my colleagues across the country, it is via the survey tool sold to healthcare facilities by the Press Ganey Company. There are also many, many online sources that rate physicians, such as this one and this one. The idea is a good one: physicians should be subject to feed-back from patients about patient perceptions of how good a job the doctors do. If nothing else, how are we otherwise to change our behavior if we don’t find out where our problems are? The surveys don’t measure medical competence, but they could be a good metric of another aspect of how good we are as physicians. But, as currently used, patient satisfaction surveys are riddled with problems. They don’t measure what they’re supposed to measure, and they can easily drive physician behavior the wrong way.

I’ve read the Press Ganey survey forms, and the questions they ask are all very reasonable. I’d like to see the results if all the parents of my patients would fill one out. But that’s the problem. It is a fundamental principle of statistics that the sample (those who fill out the survey) you use to analyze the whole data set (which would be all the patients) is representative of the entire group. This doesn’t happen. Although the forms are sent out to a random sample of patients, a very nonrandom distribution of them are returned. Perhaps only the patients who are happy, or those who are unhappy, send them back. This is in fact likely. For the analysis to have any validity at all the patients who do not return the forms must also be randomly distributed among all those sent forms. But a valid survey, one in which efforts are made to get a very high return rate using such things as follow-up calls or contacts, is much more expensive to do.

There is another problem. Patient satisfaction and good medical care do not entirely overlap. It is certainly true that an experienced and skilled physician can and should deliver bad news to patients in a way in which the patient feels understood and accepting. But not infrequently doctors have to tell a patient that what the patient wants is not good medical care. This might be something as simple as not prescribing antibiotics for a viral illness, even though the patient may want that, to not prescribing narcotics to a drug-seeking patient in the emergency department. Both of these scenarios are common, and so can be the result — a dissatisfied patient. This issue would also be solved by a getting surveys from a truly random sample of patients, since the dissatisfied antibiotic or drug-seeking ones would be washed out by all the others. But now the mad ones fill out the forms — many others toss them in the trash.

This is not a trivial issue. Recent research has strongly suggested that the most satisfied patients often don’t get the best care; they are more likely to be admitted to the hospital (an often dangerous place), and they may even have a higher death rate. The best doctors can easily have the worst patient satisfaction scores.

I don’t want you to think I am against holding physicians accountable for what we do — I’m not. Patient satisfaction is a key component of how to do that. But we must have better tools, especially since we are now tying a doctor’s income to the satisfaction score. What we do now can easily result in statistical nonsense. Any scientist will tell you that bad data are worse than no data.

For what it’s worth, I looked for my own scores on several of the big physician rating sites. Good news! I got 4 stars (excellent)! The number of reviews I could find, out of the thousands of patients I’ve seen over 35 years of practice? One — a single review. Maybe it just means I’m not very memorable. But thanks anyway to whoever the reviewer was. Still, one out of many thousands doesn’t seem to be a very representative sample.

Teenagers texting while driving: what data do we have about the risk and prevalence?

May 14, 2014  |  General  |  No Comments

By now everyone should know that texting while driving is dangerous. Just talking on a cell phone while driving can have the same overall effect on attention and reaction time as driving while intoxicated. Texting while driving increases crash risk by 23-fold. But like most drivers I still pass cars with drivers bent over their phones texting away. Although we oldsters are catching up, texting is still more prevalent among younger people, especially teenagers. Teenage drivers already have a higher risk of getting into accidents anyway just owing to their inexperience. What do we know about what texting adds to this? We already know that 13% of all car crashes of 18-20 year-olds occur when they are using some sort of mobile device. A recent study gives us some information about how common texting is in particular.

The study was a survey of 8,505 students older than 16 and assessed texting behavior, as well as the association of texting with other high risk behaviors while driving. The results should cause us some concern. The results showed that nearly half of the students had done this during the previous month. More than that, texting while driving was associated with a significantly higher probability of the teenager not wearing a seat belt, riding in a car in which the driver had been drinking, or, most concerning, themselves driving after drinking.

I’m not surprised by these associations since risky behavior in teenagers comes as a bundle — if they do one risky thing they are more likely to do another. But parents should be aware of the particular danger of texting and talk to their kids about it. And, of course, we should set a good example by not texting while driving ourselves.

Is the ADHD fad finally going to break?

Is the ADHD fad finally going to break?

May 6, 2014  |  General  |  No Comments

Few pediatricians doubt that ADHD — attention deficit hyperactivity disorder — is a real thing than can be quite disabling to some children. Further, few pediatricians question that stimulant medications like Adderall and Concerta can be very helpful for these children. But any reasonable person should be skeptical that 11% of all children and 20% of teenage boys have ADHD requiring medication. Those are the recent numbers reported by the Centers for Disease Control. The person most responsible for identifying ADHD and researching for 30 years how to treat it is Dr. Keith Conners, emeritus professor of psychology at Duke University. In a recent interview he had this to say about this apparent epidemic:

“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” . . . “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

There is big money to be made in ADHD. As you can see from the graph above, sales of stimulants have risen 500% since 2002. ADHD is also just the kind of disorder the drug companies love — a chronic condition that requires daily medication for many years. They are far less interested in developing drugs that cure things because the market goes away. Drug companies market ADHD. They sponsor a large number of conferences for physicians and mental health workers encouraging them to diagnose it and, of course, to treat it. Patient advocacy groups for ADHD are helpful. But they also get a huge chunk of their funding from the drug industry, something few people know. And now a whole new frontier for Big Pharma has opened up with the identification that some adults have ADHD and respond to stimulant therapy. For those who suffer from ADHD the therapy helps significantly. But you can see the temptation to over-diagnosis it in adults, too. With all these prescriptions you can also see the ease with which they can be diverted to the illicit drug market. That happens frequently.

Is there any hope of moderating this trend, of getting the prescription numbers back down out of the stratosphere? A recent editorial in Psychiatric Times by Allen Frances sees some hope. That hope is based in the common sense of people pushing back. Here is what he has to say about that:

The percentage of kids being diagnosed (11% overall and 20% of teenage boys) is so absurdly high that reasonable people can no longer accept that the label is being applied with anything approaching sufficient care and caution.

I hope he’s correct. The principal problem with diagnosing ADHD is that there is no specific test for it, no blood test or scan that doctors can use to decide who has it. The diagnosis is made by ticking off items on a checklist, a checklist that was devised by committees of experts, committees which periodically change their minds and modify the diagnostic criteria. Inevitably the diagnosis has a fair amount of subjectivity built into it. Dr. Frances also reminds us that psychiatry has always wrestled with the subjective nature of mental illness, a situation that is ripe for diagnostic fads and fashions:

The history of psychiatry is littered with the periodic recurrence of fad diagnoses that suddenly achieve prominence and then just as suddenly fade away. Human distress is always hard to explain and sometimes hard to tolerate. Diagnostic labels, even false ones, can gain great and undeserved popularity because they seem to explain the otherwise unexplainable and provide hope that describing a problem will lead to improving it. And once you have a diagnostic hammer, everything begins looking like a nail.

I think that is quite perceptive.