By Kim Bellard, June 20, 2011
There are times when I despair about the prospects for improving our health care system.
To illustrate, let me give some examples – two from the physicians’ standpoint, two from the patients’ standpoint – and then see what we might conclude.
Recently JAMA reported the results of a study by Dr. William Borden and others on the treatment of heart patients with clogged arteries, following up on their 2007 research. That earlier research indicated that patients receiving drug therapy fared equally well as angioplasty in preventing heart attacks, and so should be tried before performing the more invasive, more costly surgical approach. The 2007 study was widely reported on, and was expected to reduce the number of patients receiving the surgical approach. The new research indicates that in the two years after the 2007 results were released, there was virtually no impact in the percentage of patients receiving the drug treatment approach. Experts cite time being needed to change practice patterns as well as patient demand for the “high tech,” more immediate impact surgical approach as reasons for the modest impact.
All right, maybe that’s not the best example. Perhaps the original study results simply hadn’t been out long enough to change practice patterns, and most likely switching to the medication approach would have significant revenue impacts on both hospitals and on vascular surgeons that might create resistance to change. Let’s take a less controversial topic: hand washing. This is a practice whose clinical benefits have been well known for, what, 150+ years? Moreover, it is one whose benefits pretty much everyone -- physicians, nurses, other health care workers, and patients -- agree upon. Despite that, the accepted wisdom is that health care professionals appropriately wash their hands less than fifty percent of the time, with some estimates as low as thirty percent. One study indicated that the baseline rate of hand hygiene compliance was 26% in ICUs and 36% in non-ICUs…and after a year of feedback these rates increased to 37% and 51%, respectively, which is hardly cause for celebration. Again, the problem has been well understood for years, with vigorous attempts to highlight best practices in order to improve compliance, yet the problem persists.
Patients have their own blind spots. Take antibiotic compliance. Antibiotics were one of the great medical advances of the 20th century, and remain one of the leading methods of treatment for many conditions. Unfortunately, the literature is clear that patients often are noncompliant with their prescribed programs, which can reduce their effectiveness significantly. One study conducted a review of various other studies and found that the mean dose-taking compliance was only 71%. Compliance was higher in once-daily regimes, falling to 51% if the dose required four daily doses. Patients are told to take the full course, but forget to take doses or stop once their symptoms diminish. The failure to complete a course of treatment can cause relapses and is often cited as a reason for increased antibiotic resistance.
Then there is the obesity epidemic in America. The facts are well known: recent estimates put the incidence of obesity at a third of all adults. That percentage is double the prevalence thirty years ago. Obesity, of course, is associated with a number of serious health concerns, including high blood pressure, diabetes, and heart disease. To make things worse, it is estimated that another third of adults are overweight, meaning that two-thirds of American adults have a weight problem. The comparable figure for children is an equally startling one-third.
Sadly, many people do not even have an accurate perception of their weight-related health risk. A survey by Harris Interactive/HealthDay found that thirty percent of the overweight felt their weight was normal, while 70% of those considered obese thought they were merely overweight. Interestingly, respondents to the Harris survey cited lack of exercise as the key culprit for being heavier than they should, yet pointed to surgery as the most effective weight loss method, followed by prescription drugs. Enough said.
In previous blogs I’ve been a strong advocate of the importance of using information to help health care professionals improve their performance and to help consumers make better decisions about their choice of treatments and health care professionals. With examples like the above, though, it seems that information is necessary but definitely not sufficient. In each case, the “right” thing to do was fairly well established empirically, widely communicated, yet consumers and even health care professionals continued to make the “wrong” choice. And by no means are these examples the only ones of their type in health care, or even the most egregious. Just this week researchers reported that as many as 70,000 Americans may die of heart failure each year because they are not receiving the optimal treatments called for by accepted national guidelines.
Between medical errors, sub-optimal care, and our own neglect of our health, it’s a wonder anyone survives the health care system. It’s getting to the point when I’m afraid to read any more studies.
The basic problem is that behaviors are hard to change, even when given information about how that behavior should be changed. I point to the example of car safety belts. They were widely installed in most cars by the 1960’s, and were well understand to reduce traffic fatalities significantly, yet by the early 1980’s usage was still as low as 11%. Today usage is up to 85% (and one could be dismayed it is “only” 85%), but it took a generation to for wearing seat belts to become the norm.
Information is essential. Incentives are appropriate. Neither, even when used in combination, may be enough to change behavior until and unless the individuals in question see the need for change, and the value to themselves in making the change. We need to do a better job of making that case.
The good news is that we can learn new behaviors when we want to – for example, almost 70% of American’s with mobile phones use them for texting (according to Comscore), a feature that barely existed ten years ago. If we can make room in our lives for that, certainly there should be room for us to do better at improving our health and demanding better health care. Or so I hope.