Entries in Clinical & Quality (42)


I Really Wish You Wouldn't Do That

By Kim Bellard, September 22, 2016

Digital rectal exams (DREs) typify much of what's wrong with our health care system.  Men dread going to go get them, and -- oh, by the way – they apparently don't actually provide much value. By the same token, routine pelvic exams for healthy women also don't have any proven value either.

The recent conclusions about DREs come from a new study.  One of the researchers, Dr. Ryan Terlecki, declared: "The evidence suggests that in most cases, it is time to abandon the digital rectal exam (DRE).  Our findings will likely be welcomed by patients and doctors alike."

The study actually questioned doing DREs when PSA tests were available, but it's not as if PSA tests themselves have unquestioned value.  Even the American Urological Association came out a few years ago against routine PSA tests, citing the number of false positives and resulting unnecessary treatments.

Indeed, the value of even treating the cancer that DREs and PSAs are trying to detect -- prostate cancer -- has come under new scrutiny.  A new study tracked prostate cancer patients for ten years, and found "no significant difference" in mortality between those getting surgery, radiation, or simple active monitoring.

The surgery and radiation, on the other hand, had some unwelcome side effects.  Forty-six percent of men who had their prostate removed were wearing adult diapers six months later, and impotence was reported in 88% of surgical patients and 78% of radiation patients.

As for the pelvic exam, about three-fourths of preventive visits to OB-GYNs include them, over 60 million visits annually.  They're not very good at either identifying or ruling out ovarian cancer, and the asymptomatic conditions they can detect don't have much data to indicate that treating them early offers any advantage to simply waiting for symptoms.

Or take mammograms.  Mammograms are uncomfortable, have significant false positive/over-diagnosis rates, and costs us something like $4b annually in unnecessary costs, yet remain the "gold standard."

Then there is everyone's favorite test -- colonoscopies.  Only about two-thirds of us are getting them as often as recommended, and over a quarter of us have never had one.  There are other alternatives, including a "virtual" colonoscopy and now even a pill version of it, but neither has done much to displace the traditional colonoscopy.  And all of those options still require what many regard as the worst part of the procedure, the prep cleansing.

The final example is what researchers recently called an "epidemic" of thyroid cancer, which they attributed to overdiagnosis. In fact, according to the researchers: "The majority of the overdiagnosed thyroid cancer cases undergo total thyroidectomy and frequently other harmful treatments, without proven benefits in terms of improved survival."  Not only that, once they've had the surgery, most patients will have to take thyroid hormones the rest of their lives.

All of these examples happen to relate to cancer, although there certainly are similar examples with other diseases/conditions (e.g., appendectomy versus antibiotics for uncomplicated appendicitis).

Two conclusions:

1.  If we're going to have unpleasant things done to us, they better be based on facts

2.  We should do everything we can to make unpleasant things, well, less unpleasant:

Let's get right on those.


This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting




Common Culture – A source of strength for integrated delivery systems 

By Cathy Eddy, Health Plan Alliance, July 25, 2016

On July 20, I had the opportunity to be part of a discussion that American Hospital Association and Sharp Healthcare hosted in San Diego for integrated delivery systems with health plans. I was asked to facilitate an exchange on key trends in product innovation.

During the day the discussion hit on many of the national trends we are seeing in our work with health plans around the country:

  • Strategic Value
  • Growth
  • Changes in Ownership
  • Alignment and Intersection
  • Government Oversight

During my session, we went into depth about the need for alignment between payers and providers and the key intersection points where health systems and their provider-sponsored health plans need to work in tandem to be successful. These areas are:

  • Governance
  • Customer experience
  • Contracting strategy
  • Risk adjustment
  • Quality metrics
  • Clinical integration
  • Informatics and analytics
  • Technology assessment and IT infrastructure

Jim Hinton, President & CEO, Presbyterian Healthcare Services who chaired the meeting, suggested I add a slide about Culture, another area that is a key to success. He shared that his team will call out when the word “side” is mentioned. I’ve been on the Presbyterian Health Plan board for 10 years and the organization does a great job of looking at its challenges and opportunities from a system point of view. We have an annual planning retreat with the system and health plan boards that contribute to a common culture at the governance level.  Jim’s comment reminded us that words matter.  So does culture.

Mike Murphy, CEO of Sharp Healthcare, led a discussion with a team of his executives including Melissa Hayden Cook, the CEO of Sharp Health Plan. They did a great overview about how they work as an integrated health system. This organization has built the “Sharp Experience” that drives a common culture. For the past 15 years, Sharp has held annual all-employee meetings  – three sessions where 17,000 employees, 2,600 physicians and 2,000 volunteers are invited to take a bus trip to the convention center and recommit to Sharp Healthcare and their role with the system. Their vision: To be the best health care system in the universe!

Integrated Delivery Systems often include several business models and that can result in different cultures. The language of a health plan is different than the one used by providers. The meaning given to the same words can be different – for instance, revenue. In a health plan, revenue comes from premium dollars, but payers see provider revenue as a cost. Roles can have the same title, but different responsibilities  -- care manager is just one example. It is a challenge for our integrated delivery systems to develop a common culture.  Kudos to Sharp and Presbyterian for the work they have done in this arena.

Value-based payments will drive the need for collaboration. Population health focuses on the care continuum. The customer experience is often a reflection of the system’s culture…positive when everyone is working with a common set of values and negative when the hand-offs are confusing and disjointed. As we strive to successfully integrate providers and payers, the value of a common culture can be an important key to success.

So how healthy is your culture? Listen carefully to see the words that are a part of conversations in your health system to see if you are thinking like an integrated system.

This post originally apperared on the Health Plan Alliance Blog on June 28th, 2016. You can see the original at http://www.healthplanalliance.org/News/166/Common-Culture--A-source-of-strength-for-integrated-delivery-systems and see all the Health Plan Alliance Blog posts at http://www.healthplanalliance.org/hpa/Blog.asp


Practicing in an Age of Uncertainty

By Kim Bellard, May 27, 2016

If you've ever had a hard time trying to decide what's best for your health, perhaps you can take comfort in the fact that physicians often aren't so sure either. 

Or perhaps not.

new study in Annals of Surgery, and nicely reported on by Julia Belluz inVox, focused on surgical uncertainty.  The researchers sent four detailed clinical vignettes to a national sample of surgeons, seeking to get their assessment on the risks/benefits of operative and non-operative treatment, as well as their recommendations. You'd like to think there was good consensus on what to do, but that was not the case.

In one of the vignettes, involving a 68 year-old patient with a small bowel blockage, there was fairly universal agreement -- 85% -- that surgery was the best option.  In the other three vignettes, though, the surgeons were fairly evenly split about whether to operate or not, even on something as common as appendicitis. 

So, there may be a "right" answer but you might as well flip a coin in terms of getting it, or there may just not be a right answer.  Both options are troubling.

The authors believe that surgeons are less likely to want to operate as their perception of surgical risk increased and the benefits of non-operative treatment increased, and more likely to want to operate as their perception of surgical benefit increased and non-operative risk increased.  The problem is that surgeons vary dramatically -- literally from 0 to 100% -- on their perceptions of those risks.

Most surgeons based their estimates of risks/benefits on their experience, their training, and -- if you're lucky -- on whatever literature might be available, but it is doubtful that we can usually expect an objective, quantifiable assessment. 

The American College of Surgeons has developed a "surgical risk calculator" to help surgeons better gauge these risks, using data from a large dataset of patients.  However, an earlier related study from the same team of researchers found that it doesn't make much difference.  The calculator did narrow the variability of surgeons' assessment of risk, but: "Interestingly, it did not alter their reported likelihood of recommending an operation."

Oh, well.

It is not just surgeons who aren't always sure of the right course of action, of course.  A study in the American Journal of Managed Care found that 62% of physicians reported that they found the "uncertainty involved in providing patient care disconcerting."  The discomfort with uncertainty did not vary appreciably between type of specialty.

Then there is the example of PSA tests.  In 2008 the US Preventive Services Task Force recommended routine PSA tests not be given to men over 75, and in 2012 broadened that recommendation to all ages.  Yet data suggest that the group least likely to need the tests -- men over 75 -- had the smallest declines in rates of testing.  Almost 40% of this age group are still getting the test, which is not far from the previous rates. 

As one researcher told The New York Times,   "That’s just insanity...bad medicine, poor use of health care resources and poor decision-making.”

There's all too much of that in our health care system.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


What Is the Difference Between Population Health, Community Health and Public Health?

by Clive Riddle, February 12, 2016

What Is the Difference Between Population Health, Community Health and Public Health? That is the question asked in the ThoughtLeaders Corner in this month’s issue of Population Health News. Here’s what some population health experts had to share:

Garth Graham, M.D., MPH, President of Aetna Foundation says “throughout medical school and residency, I paid close attention to my mentors in their efforts to make an impact both on the individual patient and on the broader public health level to influence health outcomes in entire communities. Today, as a cardiologist and president of the Aetna Foundation, I work every day to follow in their footsteps by looking at three distinct areas: population health, community health and public health.  When talking about population health, we are describing health and healthcare outcomes that impact a specific group of people being tracked and managed for specified health conditions. For example, at the Aetna Foundation, we’re working to bridge the health divide by paying close attention to chronic diseases, such as heart disease and diabetes, that disproportionately affect African Americans.”

Graham continues: “Community health broadens the scope, going beyond traditional health and healthcare needs to factor in the social determinants of health, such as education, employment, public safety and more. In our work with communities, we know factors such as access to information and services can have a direct impact on community health. As we look at the broader tapestry of national and state indicators, we see public health unfold beyond a specific community or group. It is the 10,000-foot view that helps us define the health of an entire nation. At the Aetna Foundation, we know that where you live can make a dramatic impact on your health. According to data from the Centers for Disease Control and Prevention (CDC), your zip code is a greater indicator of your health than your genetic code. As we work to improve health outcomes and close health divides for underserved communities in our nation, we can all contribute by sparking change—community by community, city block by city block. “ 

Alexis Pezzullo, Chief Growth Officer for DST Health Solutions offers this take: “One of the favorable consequences of the ACA’s passage has been the re-ignition of discussion around ways to enhance and sustain health in individuals, groups and populations. Stakeholders are thinking about and collaborating in various ways to improve health outcomes and address value-based utilization of healthcare resources. Not too surprisingly, the importance of public and community health efforts is becoming increasingly clear. Public health by definition is the science of protecting and improving health of entire populations, from neighborhoods to countries, through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases.”

Pezzullo contrasts that “community health, on the other hand, is a field of public health centered on the study and enhancement of the health characteristics of biological communities. While the term can be broadly defined, community health tends to focus services, education and research on geographical areas with shared characteristics. Population health, meanwhile, is concerned with the distribution of health outcomes across a group of individuals. This field includes health outcomes, patterns of health determinants and policies and interventions that link the two. Improving ‘total’ population health requires partners across public health, healthcare organizations, community organizations and businesses. Today’s population health management necessitates innovative approaches that address the complexity involved in analyzing data, evaluating patient risk and effectively managing care. The cumulative value of these efforts has never been fully realized. As the healthcare industry seeks to optimize outcomes, changing strategies, capabilities and actions to leverage synergies across these health ecosystems is essential.            

Deborah Dorman-Rodriguez, Leader, Healthcare Practice Group, Freeborn & Peters LLP offers that “the terms population health, community health and public health are often used interchangeably even though they are somewhat distinct. Population health is now commonly used in the post-ACA environment in association with the Triple Aim of improving the quality of care, improving the health of populations and reducing the per capita cost of healthcare. David Kindig and Greg Stoddart first defined population health in 2003 as: ‘health outcomes of a group of individuals, including the distribution of such outcomes within the group.’ (Kindig D, Stoddart G. “What Is Population Health?” Am J Public Health. March 2003;93(3):380-383.)”

Dorman-Rodriguez goes on to say that “the definition did not include the cost or provider intervention aspects of healthcare. The evolution of the term over the last 10 to 12 years indicates there is not one specific definition that is universally recognized. It appears, however, that the concept of investment/cost and provider intervention/influence is likely to be included. In contrast, the terms public health and community health have traditionally meant a focus on the improved health of a population. The WHO defines public health broadly as ‘all organized measures (whether public or private) to prevent disease, promote health and prolong life among the population as a whole.’ The CDC Foundation defines public health as being ‘concerned with protecting the health of entire populations.’ Community health is often seen as a field within public health, focusing on the health of a particular population group that has common characteristics, such as culture, work, physical traits, geography or other demographics. All three terms are likely to evolve in their respective meanings given the current emphasis on improving healthcare outcomes.”  

Finally, Neil Smiley, CEO/Founder of Loopback Analytics has this to say: “Population health is a health improvement strategy for risk-based entities, such as managed care plans, self-insured employers and accountable care organizations that are financially responsible for clinical and economic outcomes of beneficiaries under their care. Population health competencies include analytics to proactively identify individuals with shared characteristics, such as chronic conditions, payer classifications, patient demographics and other risk factors. Once a population of interest has been identified, individuals are matched with interventions to manage health risk, with a feedback loop to measure clinical and economic efficacy. “

Smiley states that “community health is defined by local geography, such as a town, city or county. Communities typically include many risk-based entities, each operating their respective population health strategies. Whereas population health is often focused on clinical interventions, community health addresses non-clinical interventions, such as social services, transportation, housing and education provided by non-profits and community-based organizations. Public health spans both risk-based entities and communities with a focus on clinical research, health policy, regulations and quality and safety standards. Public health encompasses environmental factors that can impact the health of a population, such as infectious disease control (Centers for Disease Control and Prevention), air and water quality (Environmental Protection Agency) and safety of the food supply (U.S. Food & Drug Administration). Ideally, population, community and public health initiatives work together to continuously improve healthcare delivery and outcomes. “

More information about Population Health News is available at www.PopulationHealthNews.com


Doing Different Differently

By Kim Bellard, January 28, 2016

I was all set to write about bacteriophages, then I realized that what appealed to me about them was as an example of attacking mainstream problems with non-mainstream solutions. So I decided to write more generally about how organizations are trying to encourage that.

Let's start with IBM. Big Blue is trying to reinvent itself as a company that uses "design thinking" to develop products and services.

Their design principles emphasize "making users your North Star," using collaborative multidisciplinary teams, "restless reinvention," and a continuous loop of "observe/reflect/make."

So far, about 10,000 employees have gone through the design bootcamp, and around 100 products have been developed using design thinking. Those are drops in the bucket for IBM, but the approach is an audacious and long overdue attempt for IBM to stay relevant in a millennium in which Apple has reminded companies about the importance of design.

Or take Microsoft. If there is any doubt that Microsoft is well on its way to doing things differently, look at the Surface Book or Surface Pro, each of which has won rave reviews. CEO Satya Nadella has been shaking things up ever since he took over two years ago.

One of Mr. Nadella's actions was to break up Microsoft's Research group, which had been kept separate from the day-to-day action. Bloomberg reports that Mr. Nadella has insisted that the research teams work hand-in-hand with the product teams to get new ideas into actual products quicker.

Mr. Nadella has emphasized, "we need to be open to new ideas, and Microsoft Research is where they will come from." This attitude led to Skype Translator becoming an actual product within three months of Mr. Nadella learning about the underlying research.

Venture capitalist Anshu Storm has a theory -- "stack fallacy" -- that he believes explains why so many big companies fail to innovate. The theory posits that many companies suffer from the "mistaken belief that it is trivial to build the layer above yours." 

He cites how Apple has built great devices but also has missed on simple apps, or IBM's classic blindspot about letting Microsoft own the OS layer that ran their PCs.

In his view, "Product management is the art of knowing what to build." The trouble is that too many companies focus on the how and not enough on the "why."

For example, think about hospitals. They're trying hard to position themselves as patient-centered health systems, but no one who has been in a hospital can believe that hospitals see patients as the customer. Hospital gowns? Waking patients up in the middle of the night to take vitals? Corridors upon winding corridors?

We need the health care experience to be less like health care and more like things we actually like. Nick de la Mare suggests that hospitals (and schools) "should be more like theme parks," and that designers should be aiming for "magical experiences."

That's the attitude we need to be taking as we try to innovate; it's not just doing more, but really rethinking the overall consumer experience. I was particularly struck by Mr. de la Mare's caution: 

The trick is to deploy technology strategically and sparingly, since new tools tend to introduce unintended complexities....A hospital patient may feel similarly overwhelmed by impersonal and bureaucratic processes that seem to serve the health care provider at their expense. Just because we have the technology to do something, doesn’t mean we should.

There is cool innovation going on within health care. David Chase, for example, raves about how Zoom+ (which I've written about before) has revamped the ER experience, and there is no shortage of other health care companies hoping to be disruptive (e.g., Becker's list of 30).

There is plenty of incremental innovation going on, and health care sure can use it, but I continue to be on the lookout for breath-taking innovation -- innovations that surprise, excite, and delight.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting