Entries in Clinical & Quality (54)


Healthcare Bowl 2017: Atlanta vs New England

By Clive Riddle, February 3, 2017


The Atlanta Falcons and New England Patriots square off this Sunday in Houston during a Lady Gaga concert (the halftime show.) But another performance between this two cities is playing out on a daily basis – healthcare indicators. Let’s see how Atlanta vs. New England stack up in a healthcare bowl.


Instead of the venue for this comparison being NRG stadium in Houston, we find ourselves at The Big Cities Health Coalition, a “forum for the leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of the 54 million people they serve.” Their playing field is a Data Platform that features over 17,000 data points across 28 large cities.


Here’s the selected results from their data platform. Let’s score 7 points when one city’s indicator bests the US average and the other city is below the US average, and 3 points the better city when both or neither best the US average. Data is from 2013, and represents Fulton County for Atlanta and the Boston metropolitan area for New England.


  • ·         Uninsured Rate: Atlanta 16.9%; Boston 4.4%; US 14.5%. New England takes a 7-0 lead.


  • ·         Adult Obesity Rate: Atlanta 25.4%; Boston 21.7%; US 28.3%. New England extends their lead to 10-0.


  • ·         Heart Disease Mortality per 100,000:  Atlanta 157.3; Boston 133.6; US 169.8. New England goes up 13-0.


  • ·         Diabetes Mortality per 100,000: Atlanta 19.3; Boston 19.4; US 21.2. To close to call. The score at halftime remains New England 13, Atlanta 0.


  • ·         Asthma Annual ER visits per 10,000: Atlanta 49.8; Boston 125.8%; No US average provided. Atlanta now trails 13-3.


  • ·         Opioid related unintentional drug overdose mortality rate per 100,000: Atlanta: 9.4; Boston 16.8; US 4.2. Atlanta cuts further into the lead, now trailing 13-6


  • ·         Smoking: Atlanta 16.0%; Boston 18.4%; US 17.9%. Atlanta ties the score 13-13.


  • ·         All Cancer Mortality per 100,000: Atlanta 159.3; Boston 176.1; US 163.2. Atlanta wins 20-13.


There you have it – Atlanta wins the Healthcare Bowl 2017 by a score of 20-13.


Understanding Impact of Socioeconomic Data on Health Outcomes

By Claire Thayer, January 26, 2017

While advancements in medical technologies have contributed to improved health outcomes, health care systems are increasingly retooling their focus to understanding the basic socio determinants of health, the underlying factors of how socio and economic conditions are correlated to health outcomes of patient populations along with the role of local communities in addressing these issues.  As health care providers undertake more risk with population health management and value-based payment arrangements, health care providers are being held accountable not only health care costs, but also the health of their patient populations.

The CDC outlines some of the factors related to health outcomes as:

  • ·         How a person develops during the first few years of life (early childhood development)
  • ·         How much education a person obtains
  • ·         Being able to get and keep a job
  • ·         What kind of work a person does
  • ·         Having food or being able to get food (food security)
  • ·         Having access to health services and the quality of those services
  • ·         Housing status
  • ·         How much money a person earns
  • ·         Discrimination and social support

This week, a special edition of the MCOL Infographic, co-sponsored by LexisNexis Health Care, highlights many of the key socioeconomic factors impacting health outcomes for patient populations:




Additional reading:

Tackling Patients’ Social Problems Can Cut Health Costs, Kaiser Health News, January 23, 2017

Socio Determinants of Health: Know What Affects Health, CDC

Healthy People 2020 – Socio Determinants of Health, Health

Using Social Determinants of Health Data to Improve Health Care and Health: A Learning Report, Robert Wood Johnson Foundation, May 2016

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation, November 4, 2015.



MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.



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 and see all the Health Plan Alliance Blog posts at


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